a g e n d a 1 apologies for absence and chairperson’s ... papers/2016/tsh board... · board...

THE STATE HOSPITALS BOARD FOR SCOTLAND

Meeting of The State Hospitals Board for Scotland to be held on Thursday 25 February 2015 at 9.45am in the boardroom, The State Hospital, Carstairs.

A G E N D A

1 Apologies for absence and Chairperson’s introductory remarks - Chair 2 Conflicts of Interest - Chair 3 To approve the Minutes of the previous meeting held on 10 December 2015 Enclosed - Chair 4 Action Points from previous meeting and Matters Arising Enclosed - Chair 5 2014/15 Annual Review - Letter from Minister Enclosed - Chair CLINICAL GOVERNANCE: 6 Volunteering Service at The State Hospital – Update - Report by Interim Nursing Director and Involvement and Equality Lead Enclosed 7 Patient Advocacy Service – Annual Report - Report by Interim Nursing Director and Patient Advocacy Service Manager Enclosed 8 Patient Learning Report - Report by Interim Nursing Director and Training and Professional Development Manager Enclosed 9 Clinical Governance Committee held on 18 February 2016 - Summary of Business Discussed – Chair of Committee Verbal STAFF GOVERNANCE: 10 Workforce Review – Update of Progress - Report by Chief Executive Verbal 11 Values and Behaviours - Report by Human Resources Director Enclosed 12 Staff Governance Committee held on 3 December 2015 - Draft Minutes – Chair of Committee Enclosed CORPORATE GOVERNANCE: 13 Local Delivery Plan (LDP) Performance Report to 31 December 2015 - Report by Finance and Performance Management Director Enclosed 14 Draft Local Delivery Plan (LDP) 2016-2021 - Report by Finance and Performance Management Director Enclosed

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15 Finance Report as at 31 January 2016 - Report by Finance and Performance Management Director Enclosed 16 International Travel Requests - Report by Chief Executive Enclosed 17 Audit Committee Meeting held on 21 January 2016 - Draft Minutes – Chair of Committee Enclosed 18 Chief Executive’s Report - Report by Chief Executive: Enclosed 19 Any Other Business 20 Date and Time of next meeting - 28 April 2016 at 9.45am in the boardroom, The State Hospital 21 Exclusion of Public and Press To consider whether to approve a motion to exclude the public and press during consideration of the items listed at Part II of the agenda in view of the confidential nature of the business to be transacted.

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THE STATE HOSPITALS BOARD FOR SCOTLAND Minutes of the meeting of The State Hospitals Board for Scotland held on Thursday 10 December 2015 at 10.00am in the Boardroom, The State Hospital, Carstairs. Present: Chair Terry Currie Non-Executive Director Bill Brackenridge Non-Executive Director Elizabeth Carmichael Non-Executive Director Nicholas Johnston Chief Executive James Crichton Finance and Performance Management Director Robin McNaught Nursing Director Stephen Milloy Medical Director Lindsay Thomson In attendance: Involvement and Equality Lead Sandie Dickson (part) Security Director Doug Irwin Head of Communications Caroline McCarron HR Director Barbara Anne Nelson General Manager Mark Richards Board Secretary Jean Wade 1 APOLOGIES FOR ABSENCE AND INTRODUCTORY REMARKS Apologies were received from Anne Gillan and Maire Whitehead. Terry Currie welcomed everyone to the meeting. Members noted an update from Terry Currie on the main issues discussed at the last NHS Chairs meeting with the Cabinet Secretary on 30 November 2015. This related to the improving performance in A&E, however, some challenges remained; the Royal College of Physicians were undertaking some work to improve consistency of how patients were dealt with at Assessment Centres; Winter Plans should now be implemented; Boards were asked to ensure sufficient staffing over the festive holidays and long weekends; and Boards were also asked to ensure that Workforce Plans were fully thought through, robust and up to date. Boards were currently being consulted on the need to appoint a national Whistleblowing Officer and it was expected that everyone would contribute to this, including The State Hospital; the Staff Survey results were expected tomorrow (11 December) and the national response rate was 38%. It was expected that some Boards would have more negative results than the previous year and the concern about i-Matter and the Staff Survey running simultaneously would be reflected in the results. The Staff Survey was expected to be paused in 2016, however, the national i-Matter continuous improvement tool would continue. The State Hospital results would be discussed at the Partnership Forum the following week. The Out of Hours Review, conducted by Sir Lewis Ritchie, was being well received by the Health and Social Care community. Key stakeholders would be asked to comment on the Findings by the end of January 2016 and Scottish Government would develop an implementation plan by end of March. In the recent Spending Review, the Treasury announced its Autumn Statement and the increase to the Department of Health was higher than anticipated, however, the level of internal savings to be achieved were as expected. The draft budget for NHSScotland would be announced on 16 December 2015 and due to the forthcoming Scottish elections in 2016, would cover one year only.

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Terry Currie stated that there was no doubt that the financial challenges to be faced by NHSS would be significant, particularly in the year ahead. The Cabinet Secretary confirmed her view that the service was about to enter into a period of the most significant reform since its inception. 2 CONFLICTS OF INTEREST Other than those declared at earlier meetings, no other conflicts of interest were noted in respect of the business to be discussed. Post meeting, Jim Crichton’s appointment as Non Executive Director of SACRO was noted and recorded in the Board Members’ Register of Interests. 3 MINUTES OF THE PREVIOUS MEETING The Minutes of the previous meeting held on 29 October 2015 were approved as an accurate record. 4 ACTION POINTS FROM PREVIOUS MEETING AND MATTERS ARISING All actions were completed or progressing satisfactorily. 5 INVOLVEMENT AND EQUALITY ANNUAL REPORT Members received the Involvement and Equality Annual Report and presentation from Stephen Milloy and Sandie Dickson. Sandie Dickson summarised the Report which provided an update of progress to action plans arising from consultation with stakeholders, highlighted some of the challenges around feedback processes, alerted the Board to national development of the Spiritual and Pastoral Care Pathway, provided some re-assurance in terms of a more robust approach to Equality and Diversity and initiated development considerations relating to volunteering. A number of issues of the Annual Report were discussed in relation to the importance of continued service improvement, the value of working smarter from the feedback received in order to identify any themes and gaps in service; the challenges of the new complaints reporting process; the supportive work ongoing with Scottish Health Council towards achieving Level 3 of the Board’s Participation Standards Self Assessment; the value of the Patients’ Voice and the various comments and experiences included in the report; issues of the care pathway and the scoping exercise currently being undertaken by Clinical Forum as part of the review of the Clinical Model; the improvements required in terms of Occupational Therapy attendance at CPA meetings which Mark Richards was alert to; the Visitor Bookings process, the streamlining of which Mark Richards was reviewing; that the Board welcomed patients having the choice to share feedback through a range of opportunities; and in this respect, that there was a need for more work to be done in terms of culture and behaviours to ensure patients were at the centre of care at the Hospital. In conclusion, Members agreed with Terry Currie that the report was very positive and the very good work undertaken by the Department was acknowledged. Members noted the progress outlined in the Involvement and Equality Service Annual Report; and the emerging issues and key actions.

Sandie Dickson left the meeting at this point. 6 SUPPORTING HEALTHY CHOICES – RECOMMENDATIONS FROM CONSULTATION All Members agreed that this item would be discussed in private in Part II of the meeting.

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7 CLINICAL GOVERNANCE COMMITTEE MEETING HELD ON 12 NOVEMBER 2015 Members received draft Minutes of the Clinical Governance Committee meeting held 12 November 2015 from Nicholas Johnston who summarised some of the discussions that had taken place. This related to the Review of the Clinical Governance Annual Report and the agreed way forward; the progress outlined in the Physical Health Steering Group Annual Report and the concerns to be noted in the Clinical Governance Annual Report in terms of obesity levels and measurement of physical activity; the ongoing concern of capacity across the Forensic Network in respect of medium secure facilities; the retrospective analysis of formal complaints from August 2013 to November 2014, conducted by Nicholas Johnston, which confirmed that there were no patterns or recurring issues; and that going forward, it would be useful to conduct an annual retrospective review over the previous 12 month period which would assist in identifying any issues of concern. Bill Brackenridge raised the issue of information on patient movement and whether or not Board Members should have a regular briefing on this which would provide them with more current data. It was agreed that this could be included in the Chief Executive’s Report to the Board and provide statistics over the year and to report any issues of concern.

Action: Lindsay Thomson/Jim Crichton Members approved the Minutes of the Clinical Governance Committee Meeting held on 12 November 2015. 8 WORKFORCE REVIEW INTERIM REPORT Members received a report from Jim Crichton and Barbara Anne Nelson which provided the interim position in respect of the Workforce Review. Jim Crichton summarised the status of progress for each of the Workstreams identified by the defined 2020 Objectives and the overarching themes which had emerged from the work undertaken to date. A number of issues of the interim report were discussed in relation to the age of the workforce and the risks to be mitigated; the review of the Clinical Model which was inextricably linked to ensuring a clear position in the Workforce Plan; the importance of consistency in clarifying the aims of each workstream; and the Shared Services agenda, elements of which would be included in the final report to the Board. Members noted that more detail would be provided in the final report to the Board at their meeting on 28 April 2016. This would set out a clearer position showing the interface and key milestones that would emerge once recommendations from the workstreams were confirmed. Members noted the Workforce Review Interim Report. 9 PROTECTING VULNERABLE GROUPS (PVG) SCHEME Members received and noted a report from Barbara Anne Nelson which provided a Statement of Assurance to the Committee that The State Hospital had completed the retrospective PVG checking exercise for employees by the due date of October 2015. Barbara Anne Nelson confirmed that, in total, 430 staff had been processed and now held the required membership of the PVG Scheme. 10 SCOTTISH GOVERNMENT RESPONSE TO THE FREEDOM TO SPEAK UP REVIEW Members received a report from Barbara Anne Nelson in respect of the Scottish Government response to the Freedom to Speak Up Review which was chaired by Sir Robert Francis QC. The report set out revisions to the completed Action Plan that had been requested by Members at the last meeting of the Board in October when the Board’s position was outlined.

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Members noted the revisions to the Action Plan and that it was anticipated that Boards would be asked to supply this information to Scottish Government at a later date. Terry Currie advised of the arrangements for Non Executive Whistleblowing Champions following the recent consultation with Boards. The Scottish Workforce and Governance Committee (SWAG) had given a clear view that Whistleblowing Champions should be separated from investigation and escalation of cases. The key purpose of the role was to offer independent assurance and SWAG were clear that involving the Whistleblowing Champion in that process could compromise the independence required. Members agreed to Terry Currie’s proposal for Maire Whitehead to continue in the capacity of the Board’s Non Executive Whistleblowing Champion with an oversight role; and for Jim Crichton to become the Board’s official Whistleblowing Officer with responsibility for investigation and escalation of cases under the new arrangements. Any governance issues would be reported to Staff Governance Committee by the Whistleblowing Champion. 11 STAFF GOVERNANCE COMMITTEE MEETING HELD ON 3 DECEMBER 2015 Members received a summary of the discussion that had taken place at the Staff Governance Committee meeting held on 3 December 2015 from Bill Brackenridge. This related to the significant amount of discussion that had taken place on the ongoing issues of attendance management. The Committee had been advised that sickness absence had reached 10% and that 67 whole time equivalent (wte) staff were required to cover this resource deficit. The Committee was convinced that the issues were being addressed, however, there was a need to see substantial progress. Members agreed that this was not just an issue for Staff Governance Committee, but for the whole organisation. HR resources had been addressed and ownership, responsibility and support had been spread widely across the site. The arrival of the new Head of HR would help with the improvements required to address the high level of absence, a plan for which was already in place. The issue continued to be discussed in partnership and Barbara Anne Nelson advised that sustained improvement was expected over time. Members noted the summary of discussion at the last meeting of the Staff Governance Committee and that the Minute of the Meeting would be submitted for approval at the next meeting of the Board in February 2016. 12 FINANCE REPORT AS AT 31 OCTOBER 2015 Members received the Finance Report as at 31 October 2015 from Robin McNaught who summarised the information provided. It was noted that the Revenue position was showing a small underspend of £0.194m. The ‘in month’ movement was an overspend of £0.011m which was mainly associated with the timing of certain estates expenditure and a favourable adjustment had also been made to the phasing of savings. Members discussed a number of issues of the Finance Report in relation to the Savings Plans, which were expected to be achieved; the Capital budget spend and the commitments up to the financial year end. Robin McNaught was in discussion with Scottish Government on the potential to carry forward Capital underspend into the following year. Members noted the Finance Report to 31 October 2015 and that a breakeven position was expected at the year end.

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13 CHIEF EXECUTIVE’S REPORT Members received and noted a report from Jim Crichton, which reported progress on Patient Safety; Healthcare Associated Infection (HAI); and the Patient Day. Jim Crichton also provided a verbal update on a range of general issues in relation to an update on the Nursing Director Post; Feedback on the Annual Scottish patient Safety Event; the National Care Standards Review; the meeting he had with George Thomson and Mathew Linning of Volunteer Scotland; the flu vaccination programme at the Hospital, the uptake of which was slightly down on last year and reflected the national picture; and the Forensic Network Manager Recruitment and Capacity Review. Members noted the Chief Executive’s report 14 ANY OTHER BUSINESS Terry Currie advised that Stephen Milloy would retire from the post of Nursing Director at the end of January 2016. He acknowledged the major contribution Stephen had made over his 23 years service at the Hospital and on behalf of the Board expressed his thanks for the work he had undertaken during that significant period of time. Members joined Terry Currie in extending his very best wishes to Stephen Milloy for the future. 15 DATE AND TIME OF NEXT MEETING The next meeting would take place on Thursday 25 February 2016 at 9.45am in the Boardroom, The State Hospital, Carstairs. 16 EXCLUSION OF PUBLIC AND PRESS Members approved a motion to exclude the public and press during consideration of the items listed at Part II of the agenda in view of the confidential nature of the business to be transacted. ADOPTED BY THE BOARD CHAIR __________________________________________ (Signed Terry Currie) DATE 25 February 2016

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MINUTE ACTION POINTS FROM THE MEETING OF THE STATE HOSPITALS BOARD FOR SCOTLAND HELD ON 10 DECEMBER 2015

ACTION NO

AGENDA ITEM NO

ITEM

ACTION POINT

LEAD

TIMESCALE

STATUS

1

7

Clinical Governance Committee Meeting held on 12 November 2015

Information on patient movement would be included in the Chief Executive’s report to the Board.

Lindsay Thomson/

Jim Crichton

For next meeting

Complete

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 25 February 2016 Agenda Reference: Item No 6 Sponsoring Director: Interim Nursing Director Author(s): Involvement and Equality Lead Title of Report: Volunteer Service Update 1 SITUATION The State Hospital’s Board recognise the benefits of volunteer input in terms of complementing the delivery of person-centred care and treatment. The organisation, has for many years, valued this mutually beneficial relationship and are committed to developing the Volunteer Service as a part of strategic planning, supporting the delivery of safe, effective, person-centred services. In line with wider areas of service development currently under discussion, the Board may wish to consider how volunteer input can support the organisation to enhance elements of our service delivery. This is particularly relevant in respect of works streams emerging from the Patient Activity Project and the Supporting Healthy Choices initiative. 2 BACKGROUND Having discussed the Annual Involvement and Equality Service Board report in December 2015, it was agreed that, in addition to hearing the personal reflections from one of our volunteers, that a dedicated paper would be discussed by the Board at that time. The Chief Executive and Involvement and Equality Lead recently met with the Chief Executive of Volunteer Scotland with a view to exploring opportunities to broaden the concept of volunteering from an organisational perspective, specifically around the area of community benefits. In addition to considering the implications of national practice, the outcome of this meeting is shared to help inform Board discussion as we start the process of developing a new Volunteering Strategy. 3 ASSESSMENT

This report provides an update in respect of the Volunteer Service and highlights the national direction of travel, in addition to considering potential partnership working with Volunteer Scotland. 4 RECOMMENDATION The Board is invited to:

i) Note the development progress. ii) Note the ‘emerging issues’. iii) Consider the role of Volunteer Scotland in informing the refreshed local strategy iv) Discuss the concept of employee volunteering

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How does the proposal support current Policy / Strategy / LDP / Corporate Objectives

Supports delivery of Safe, Effective, Person-centred service delivery objectives within TSH Local Delivery Plan. Supports Involvement and Equality Strategy (2014-17).

Workforce Implications None

Financial Implications None

Route to the Board (Committee) Which groups were involved in contributing to the paper and recommendations.

Involvement and Equality Steering Group Volunteer Service Group

Risk Assessment (Outline any significant risks and associated mitigation)

No significant risks identified

Assessment of Impact on Stakeholder Experience

Captures feedback relating to stakeholder experience and provides opportunities to develop systems / processes through which learning from feedback is directly related to service design.

Equality Impact Assessment EQIA Screened – no issues identified.

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VOLUNTEER SERVICE UPDATE REPORT

FEBRUARY 2016

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Section Content

Page

1 Introduction.

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2 National Overview

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3 Partnership Working

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4 Local Practice

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5 Summary

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6 Recommendations

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Appendices

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Copy of Volunteering Section of Involvement and Equality Service Annual Report (Dec 2015)

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2

The State Hospital Volunteering Improvement Plan 2014-17

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2

1 INTRODUCTION The State Hospitals Board for Scotland, as a person-centred organisation, aims to create an organisational culture in which stakeholders are recognised and meaningfully involved as equal partners in service delivery. The State Hospital’s Board recognise the input of volunteers, as one of our key stakeholder groups, in terms of complementing the delivery of person-centred care and treatment. The organisation, has for many years, valued this mutually beneficial relationship and are committed to developing the Volunteer Service as a part of strategic planning, supporting the delivery of safe, effective, person-centred services. In line with wider areas of service development currently under discussion, we would wish to consider how volunteer input can support the organisation to enhance elements of service delivery. This is particularly relevant in respect of works streams emerging from the Patient Activity Project and the Supporting Healthy Choices initiative. Having discussed the Annual Involvement and Equality Service Board (appendix 1) report in December 2015, it was agreed that, in addition to hearing the personal reflections from one of our volunteers, that a dedicated paper around volunteering would be discussed by the Board at that time. 2 NATIONAL OVERVIEW

The national Volunteering Leads meeting quarterly in order to share practice and identify improvement opportunities which can be introduced across all NHS Boards in order to develop a consistent approach and reduce duplication of work. The group is chaired, on a rotational basis by one of the NHS Chairs, with additional support from the Scottish Health Council Volunteering Programme Manager and the Scottish Government Volunteering Policy Officer. The group recently produced a publication to raise the profile of volunteering within NHS Boards entitled ‘What non-executive NHS Board members can do to support volunteering’ Current work streams include:

• Development of a national training programme • Development of a national evaluation tool • Initial work around the Strategy for Volunteering in NHS Scotland. • Consideration of the challenges relating to resourcing • Sharing innovation e.g. the introduction of Spiritual Listener roles

3 PARTNERSHIP WORKING

Volunteer Scotland (VS), appointed by the Scottish Government to administer the Investing in Volunteers scheme, recently met with the Chief Executive and the Involvement and Equality Lead. VS have acknowledged that, locally, “significant progress has been made in developing the benefits both for service users and for the volunteers”. During this session, there was

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therefore a focus on opportunities to broaden volunteering input, exploring ways of engaging with a more diverse range of stakeholders, with potential broader community benefits. As part of the VS remit to work with partners to support projects, innovation and creativity in volunteering, they have offered to facilitate a local workshop, in conjunction with the Scottish Health Council, to inform development of volunteering practice. This input may be helpful in terms of connecting with community volunteer organisations with the scope to support our carers from a local perspective. This would be particularly beneficial for carers who live some distance from the Hospital and for whom visiting is therefore an infrequent support. A key area of VS support available is around research which enables NHS Boards to demonstrate and measure the impact made by volunteers. We also work closely with the Scottish Health Council, as one of our key stakeholders, in the development of our Volunteering Improvement Plan (appendix 2). In response to discussions at government level, VS are initiating conversations with NHS Boards to explore opportunities to enable NHS staff to volunteer during working hours. This practice is more prevalent in the private sector (Lloyds Bank, T-Mobile, Waitrose) where there is a view that the business benefits outweigh the costs as there is growing evidence to indicate that volunteering supports employees to develop skills, enhance job satisfaction and raise the profile of an organisation. VS have asked the Board to consider how we might support our staff to engage in this concept, sending a message around a visible commitment to the local community. Clearly, there would be financial considerations to consider, in addition to developing a policy which would enable equitable allocation of time, regardless of profession. Consideration of this initiative would of course take into account our core function of providing high quality patient care and treatment as well as competing resource demands. 4 LOCAL PRACTICE

Volunteering is now embedded within Skye Centre service delivery with considerable qualitative evidence supporting its efficacy. However it will be helpful to introduce a national evaluation tool to enable us to analyse quantitative data in conjunction with the narrative and anecdotal feedback we have, in terms of informing practice. Given the significant development of volunteering practice within the Hospital, it is appropriate that we update the Volunteering Strategy to reflect the Board’s commitment to this area of service delivery. Additionally this will enable us to develop a clear way forward for the organisation to ensure there is sustained evidence based development which is relevant to the needs of our stakeholders. A number of supporting policies will also require to be reviewed as a part of developing volunteer practices moving forward. There are significant opportunities to develop volunteering to encompass all areas of service delivery within the next development phase with a plan already in place to embed this practice within the Hubs. We are fortunate to benefit from constructive feedback from the Volunteer Service Group who have been instrumental in driving this initiative forward. In addition to Volunteer Visitors, we will shortly be introducing an outreach service, involving volunteers who currently provide input within the Patient Learning Centre. This role will help

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to support our person-centred agenda and include our ‘harder to reach’ patients who are mainly ward based, in terms of access to develop literacy and / or computer skills. 5 SUMMARY

We have developed a robust, sustainable model of volunteering, primarily within the Skye Centre. Through this process, we have applied quality improvement methodology to identify achievements, reveal gaps, analyse outcomes and deal with challenges. We are now confident that this model can be spread to the ward environment and there is an appetite within hub teams to embrace this input. An initial pilot has been agreed which will commence in Iona in the spring of this year, which will be evaluated with outputs used to inform the spread to other hubs. This process relies on sustainable resourcing to lead, manage and ensure the learning is applied to the wider remit. This area should therefore form part of current discussions informing the Business Support model. Volunteer Scotland have offered their support to develop our strategy and practice going forward however the Board should consider the implications, for us as a small NHS Board, in terms of the wider employee volunteering agenda and we would wish the agenda to be clear as part of the decision to work collaboratively with this organisation.

6 RECOMMENDATIONS Members of the Board are invited to:

i) Note the development progress. ii) Note the ‘emerging issues’. iii) Consider the role of Volunteer Scotland in informing the refreshed local strategy iv) Discuss the concept of employee volunteering

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Appendix 1

EXTRACT FROM INVOLVEMENT AND EQUALITY ANNUAL BOARD REPORT: DEC 2015

VOLUNTEER INVOLVEMENT AND ENGAGEMENT The Volunteer Service continues to grow year on year, increasing in number from 12 volunteers in 2011 to 23 currently providing input within the Hospital, primarily within the Skye Centre. Recruitment Interest remains steady from those wishing to provide voluntary input within the Hospital with the majority of enquiries coming from university students seeking to consolidate theoretical learning in preparation for seeking employment / access to higher level learning. We have formed close links with major universities / colleges in an effort to ensure that applications are relevant to this setting and that we can offer the opportunity for student volunteers to gain the experiential skills required. With a focus on complementing care and treatment plan objectives, recruitment tends to be needs led and therefore very specific in nature e.g. learning a foreign language / musical instrument. This enables us to take a targeted approach, which, in turn, reduces the time spent processing large numbers of general application forms. Roles This year we have successfully implemented a co-production model for 3 of our volunteers, involving Rowanbank and Rohallion medium secure settings. These volunteers have been enabled to visit transferred patients, thereby offering continuity in terms of those involved in providing input as Volunteer Visitors within The State Hospital. Valuable learning opportunities continue to emerge from this networking with Volunteer Lead colleagues in both settings. We have plans to broaden the range of roles across the Hospital and discussions have taken place informing an initial pilot project, relating to input identified as relevant to enhance activities within the ward environment, emerging from the Patient Day Project. We are fortunate to benefit from voluntary input from a retired member of staff who is doing some work on a curator project on behalf of the Chair, whose relevant experience and established relationships have enabled a meaningful overview of this piece of work. Through monitoring of all non-professional patient visits, data tells us that 43 of our patients currently receive no visitors. This data is monitored via the Clinical Forum who receive quarterly Clinical Outcomes Monitoring Reports with follow-up discussions at local hub clinical forums. The IES have been proactive in terms of this data, contacting clinical teams to advise that there is capacity within the volunteering service for patients who receive no visits to be referred for monthly visits from one of our volunteers.

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Investing in Volunteers Re-accreditation The Investing in Volunteers (IiV) re-accreditation process is scheduled for the spring autumn of 2016, supporting the organisation to evaluate progress over the past 3 years as well as demonstrate the efficacy of the mutually beneficial relationship we strive to support. Volunteer Development Scotland (VDS), appointed by the Scottish Government to administer the IiV scheme, recently met with the Chief Executive and the Involvement and Equality Lead. Discussions focussed on opportunities to broaden volunteering input, exploring ways of engaging with a more diverse range of stakeholders This approach may be helpful in terms of connecting with community volunteer organisations with the scope to support our carers from a local perspective. This would be particularly beneficial for carers who live some distance from the Hospital and for whom visiting is therefore an infrequent support. VDS have offered to facilitate a workshop to inform development of volunteering practice. The State Hospital Annual Review: Stakeholder Involvement Forum The Volunteer Service Group (VSG) adopted a creative method through which they shared their views about:

Volunteering in a meaningful way within the constraints of a high secure environment – turning challenges into opportunities’ Volunteers sought feedback from patients, choosing to highlight the value of volunteer input to patients through a hot air balloon model (appendix 1), illustrating many ‘uplifting’ aspects of this relationship. ‘Sandbags’, have been used to depict some of the downsides to volunteer roles, included challenges around continuity of input across the Hospital.

Following on from input within this forum, one of our volunteers has been invited to attend the February 2016 Board Meeting in person to share direct feedback relating to the volunteering experience at TSH. Volunteer Service Group The Volunteer Service Group continues to meet quarterly and have been proactive in terms of identifying opportunities for new roles and contributing to national work streams e.g. the NHS Volunteering Information System, National Care Standards Consultation. Additionally, we have volunteer representation on the Involvement and Equality Steering Group as well as the Supporting Healthy Choices Project Group. The group are currently working on the update of the Hospital’s Volunteering Policy. Mutually Beneficial Relationships “Volunteering within The State Hospital has been a very rewarding experience. I have worked within the Hospital shop and participated in many group/individual activities with patients for 3 years. This experience working alongside patients and staff has given me great confidence in working in a secure setting and with vulnerable adults. I have been actively involved in patient placements and found the award ceremony’s very rewarding for patients, staff and volunteers as they are awarded for all their efforts throughout the year. Staff and patients have been very welcoming and supportive of my input. The State Hospital has given me the relevant experience to secure 2 new jobs after my graduation from University. As my new roles involve patient care, therapy and skills within a secure

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environment, the Hospital has played a huge role in developing my personal skills. I will be sad to leave my volunteer role in order to start my career, as I have thoroughly enjoyed it. However I know that the experience current students within the Hospital have, will be of great use to them in the future. My experience has been fun and rewarding”. (LMcD 2015)

2015 State Hospital Annual Review Stakeholder Forum – Volunteer Feedback Model

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Appendix 2 The State Hospitals Board for Scotland Volunteering Improvement Plan 2014/17 This plan outlines the activities The State Hospitals Board for Scotland will undertake to develop volunteering. The plan forms part of the Hospital’s commitment to volunteering, the Refreshed Strategy for Volunteering in NHSScotland and the current Volunteering in NHSScotland Programme. The plan follows the structure of the national action plan and the agreed national outcomes for volunteering as part of the Volunteering in NHSScotland Programme. Involvement in the production of the Improvement Plan The improvement plan takes into account the local context of volunteering and has been developed in partnership with appropriate stakeholders including: Patients Volunteers Staff across the Hospital Carers Third Sector partners Scottish Health Council

Development Session A development session was held in November 2013 attended by volunteers, staff, Board members, the Scottish Health Council, Volunteer Service Leads from a number of other NHS Boards and Third Sector partners. The session was facilitated by the Volunteer Lead, Sandie Dickson, who is also the Involvement and Equality Lead, supported by the Scottish Health Council Volunteer Programme Manager. The group engaged in an interactive workshop, during which they explored current volunteer input, the challenges of embedding volunteering within this specialist service and opportunities to enhance the contribution of volunteers. Feedback from this session led to of a number of priorities being identified, informing the three year Volunteering Improvement Plan.

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The State Hospital Volunteering Improvement Plan 2014-17 Outcome 1 Volunteering contributes to Scotland’s health by

(a) enhancing the quality of the patient experience, and (b) providing opportunities to improve the health and wellbeing of volunteers themselves.

Output Action(s) Responsibility Status 1.1 Enhance awareness of staff in respect of the

purpose, value and boundaries of volunteer roles. Engage in briefing sessions with relevant staff aimed at clearly defining the responsibilities of volunteers and staff.

Involvement and Equality Lead

Ongoing

1.2 Tailored recruitment specific to needs of roles within TSH with Third Sector Interface / Volunteer Centres.

Introduce Interest Checklists. Share role descriptors. Agree on initial screening process.


Completed

1.4 New roles developed which take into account volunteer needs.

Seek feedback from Volunteer Service Group, clinical teams, Skye Centre staff


Ongoing Forms part of Patient Activity Project and Supporting Healthy Choices work streams

1.5 Enable volunteers to engage in formal learning opportunities.

Include volunteers within Equality & Diversity Training Workshop. Enable volunteer access to Learnpro system.

Involvement and Equality Lead Learning Centre Manager

Ongoing In place

1.6 Include volunteers within Occupational Health Screening.

Finalise role descriptors including risk assessments. Arrange for screening appointments as required.

Involvement and Equality Lead Occupational Health Team

In place

1

Outcome 2 The infrastructure that supports volunteering is developed, sustainable and inclusive Output Action(s) Responsibility Status (update

Jan 2016) 2.1 Ensure additional support is available. Carer Engagement Facilitator

allocated responsibility for volunteer support.


In place

2.2 Engage with staff teams who do not currently supervise volunteers to raise awareness and prepare them for supporting volunteers.

Meet with Hub Management Teams. Facilitate ward staff briefings.


Target – Jan 2015 Initial discussions taken place. Link to work streams supporting Patient Activity Project and Supporting Healthy Choices initiative

2.3 Identify potential shortfalls in budget currently allocated for volunteer support.

Separate travel and subsistence claims. Monitor volunteer support budget.


In place Currently operating within budget

2.4 Develop robust governance processes for volunteering.

Mechanisms for reporting on volunteering activity reviewed. Template created to inform quarterly feedback reports presented to Involvement and Equality Steering Group. Include volunteers within mandatory training audits.

Involvement and Equality Lead Nursing Director Learning Centre Manager

Complete Complete

2.5 Streamline electronic volunteer systems. Introduce use of national Volunteering Information System

Involvement and Equality Lead Carer Engagement Facilitator

Complete

2.6 Formalise recruitment processes in line with NHS policy.

Implement governance practices in line with Safer Pre and post Employment Checks in NHSScotland PIN Policy

Involvement and Equality Lead and HR Manager

Complete

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Outcome 3 Volunteering, and the positive contribution it makes, is widely recognised, with a culture which demonstrates its value across the partners involved.

Task Action(s) Responsibility Status 3.1 Demonstrate the value of volunteering using an

evidence based approach. Design and pilot evaluation framework to include volunteers, staff and patients for use in each role.


Contributing to national working group tasked with developing evaluation of volunteering

3.2 Enable volunteers to share feedback directly with Board members.

Include volunteers within the Hospital Annual Review process. Invite volunteer to provide feedback at a Board Meeting.


Complete Complete - Jan 2016

3.3 Enable a range of volunteers to share feedback directly within a multi-disciplinary group.

Recruit new volunteer representative (and deputy) as part of the Involvement and Equality Steering Group core membership on a 3 year term.


Complete

3.4 Contribute to national development of volunteering roles.

Share best practice with external colleagues attending Volunteer Leads Network Meetings.


Ongoing

3.5 Influence decision makers involved in national funding allocation for volunteering initiatives.

National Volunteer Leads Group Involvement and Equality Lead

Core member of this group

12

THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 25 February 2016 Agenda Reference: Item No 7 Sponsoring Director: Interim Nursing Director Author(s): Patients’ Advocacy Service Manager Title of Report: Patients’ Advocacy Service Annual Report 1 SITUATION PAS is committed to delivering a service to meet the requirements as set out in the Service Level Agreement. PAS has provided Advocacy services to all patients’ in the State Hospital for a number of years now and values the opportunity to continue to provide an independent service to patients’ that is tailored to meet the individual needs within the differing patient groups. 2 BACKGROUND The Patients’ Advocacy Service secured the SLA in April 2015 to continue to provide Advocacy to all patients’ in the State Hospital from 1st June 2015. 3 ASSESSMENT

This report provides an update in respect of the Patients’ Advocacy Service which covers the area of the service provided 4 RECOMMENDATION The Board is invited to:

i) Note the intention to further develop the service provided to new admittances ii) Note the intention to continue to deliver a service that is both valued and utilised by patients iii) Note the intention to have the service evaluated by an external auditor iv) There is effective Monitoring and Governance arrangements in place

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Supports delivery of Safe, Effective, Person-centred independent service delivery objectives within TSH Local Delivery Plan.

Workforce Implications None

Financial Implications None

Route to the Board (Committee) Which groups were involved in contributing to the paper and recommendations.

Patients’ Advocacy Service


No significant risks identified


Annual feedback questionnaire relating to stakeholder experience provides opportunities to learn and develop the service through learning from feedback which is directly related to service delivery.

Equality Impact Assessment EQIA Screened – no issues identified.

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THE STATE HOSPITALS BOARD FOR SCOTLAND Agenda Reference: Item Date of Meeting: 25 February 2016 Presented by: Ann Morton, Patients’ Advocacy Service Manager Title of Report: Patient Advocacy Service Annual Report 1 INTRODUCTION AND PURPOSE OF PAPER The purpose of this report is to provide assurance to The State Hospital Board of Directors that the Patient’ Advocacy Service (PAS) continues to meet the needs of the Hospital as set out in the Service Level Agreement.

2 SUMMARY OF CONTENT The report highlights progress made in all aspects of the Service and improvements/achievements in the year are detailed in the report. Some highlights are noted below for Board Directors. 3 KEY ISSUES

• Successful Tendering for the Service Level Agreement. . Achievements against the Key Performance Indicators in the Service Level Agreement are

being met despite being 1 staff member down.

PAS Patient Survey/questionnaire was not completed in this financial year in agreement with TSH. In TSH Patient Experience Questionnaire patients identified “Advocacy & Key Workers as the preferred 1:1 option to share feedback” and out of the 83% who stated they had used the service “78% found this input to be helpful”.

Recruited 4 new Volunteers

Location in the Skye Centre continues to improve access options for patients to advocacy.

Full and effective use is being made of the budget allocated by the Hospital for the service.

Robust arrangements are in place for education and supervision of all Advocates and Volunteers.

The service continues to be an integrated aspect of the Hospital landscape, and positive and respectful relationships exist between both organisations.

The Additional recurring £20,000 funding received from the Scottish Government following the introduction of the Patients Rights Bill continues to assist PAS to offer the support to engage with “Hard to reach patients”.

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4 FUTURE DEVELOPMENTS Section 7 of the main report identifies both organisational and service developments planned for the current 12 months. Of particular note to Board Directors will be:

Recruitment of Volunteers

Recruitment of Staff

Use additional funding stream to continue to develop service to New Admissions

Continue to develop, in tandem with the Hospital, our monitoring and recording systems.

Continue to look at developing improved and meaningful recording of outcomes for patients and stakeholders.

Support the Hospital in meeting the aspirations of the NHS quality strategy and TSH Clinical Model, particularly of the principles/priorities of person centred care.

PAS Service Planning Day

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PATIENT ADVOCACY SERVICE ANNUAL REPORT

1st April 2014 – 31st March 2015

Reference Number Issue: 1 Lead Author Ann Morton, PAS Manager Contributing Authors

Approval Group The State Hospital Board Effective Date Review Date December 2015 Responsible Officer (e.g. SMT lead)

Stephen Milloy, Nurse Director

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TABLE OF CONTENTS 1 Introduction and Highlights of the Year ............................................................................... 5 2 Governance Arrangements ................................................................................................... 7 2.1 Committee Membership and Role ........................................................................................ 7 2.2 Aims and Objectives ............................................................................................................. 7 2.3 Meeting Frequency............................................................................................................... 7 2.4 Strategy and Workforce ........................................................................................................ 8 3 Patient Contact…………………………………………………………………………………… 8 3.1 Training ................................................................................................................................ 8 3.2 New Mental Health Act ......................................................................................................... 9 3.3 Policies and Procedures ....................................................................................................... 9 3.4 Participation/Integration ........................................................................................................ 9 4 Key Performance Indicators .................................................................................................10 4.1 Overall Patient Contact ................................................................................................. 10-12 4.2 Formal Referral Routes ……………………………………………………………………………12 4.3 Patient Referral Timescales ................................................................................................13 4.4 Issues ……………………………………………………………………………………………13-15 5 Patient Story………………………………………………………………………………………….16 6 Comparison with last Annual Report ...................................................................................17 7 Areas of Good Practice/Outcome Development .................................................................17 7.1 Adult Support Investigations ………………………………………………………………………17 7.2 Ethnicity Group contacts ………………………………………………………………………… 18 7.3 Outcomes …………………………………………………………………………………..… 18-19 8 Future Areas of Work and Potential Service Developments ..............................................20 8.1 Organisational .....................................................................................................................20 8.2 Service ................................................................................................................................20 9 Finance .................................................................................................................................21 10 Next Review Date .................................................................................................................21

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1 INTRODUCTION AND HIGHLIGHTS OF THE YEAR The purpose of this report is to provide assurance to The State Hospital Board of Directors that the Patient Advocacy Service (PAS) continues to meet the needs of the Hospital as set out in the Service Level Agreement. The service we provide has the ability to adapt to the ever changing needs; we have monthly planning meetings with set priorities for the team and weekly meetings that address unexpected changes. The Mental Health Act continues to impact on our service, this year we attended 64 tribunals, 7 parole board hearings and supported 16 patients to complete an advance statement. In this year Adult Support and Protection Investigations we, as a service made 5 ASP1 referrals, had 18 discussions pre-referral and supported 9 patients in ASPI interviews. The service dealt with 2512 issues; 1309 were legal (52% of the total). Hospital issues accounted for a further 7% and quality of life 30%. Of the 67 complaints recorded, 27 were formal, 2 were informal, 35 were locally resolved; 3 were not taken forward. The Skye Centre drop-in continues to be valued and accessed by patients with 563 contacts in the drop-in, which related to 89 patients. The number of times each patient was seen ranged from 27 patients with one contact to one patient with 66 contacts; average contact 6 per patient. Feedback from patients continues to be very positive with patients telling us they like how they can drop in to speak to us formally or informally and also can phone to book a time to see an advocate. Average patient contact at the drop-in per month over the year was 47, in total, 1952 contacts were made. We have 1 Patient Representative on our Board of Directors this year and are looking to start succession planning for the year ahead. PAS continues to see patient involvement as crucial to the service and recognises that it enhances the quality of the service we provide and signifies the importance of hearing directly from patients about their experiences in order to continue to meet the changing needs in the hospital environment. We are actively involved in raising the profile of PAS in The State Hospital, delivering 10 advocacy inductions to new staff groups within the hospital throughout the year. We also gave further in-depth inductions to 6 others (e.g. new OT, students) who wanted to know more about Advocacy. We have advocacy representation on key working groups including Equality & Diversity Steering Group, Child & Adult Protection Forum and Mental Health Tribunal Advocacy Reference Group. We had another successful Annual General meeting in October 2015 where we delivered our Annual Report 2014-2015. Our 2 new patients’ representatives and the chair of the Patient Partnership Group took part in the AGM by video conference. Please see the extract from our graphics recorded during the AGM on page 6. .

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2 GOVERNANCE ARRANGEMENTS

The Patient Advocacy Service has a dual accountability: As an independent company limited by guarantee – to the PAS Independent Board of

Directors.

As a service commissioned by the State Hospital, to report annually to The State Hospital Board of Directors – to provide assurance that the service meets with the specification and performance targets set by the Service Level Agreement. The Involvement & Equality Steering Group receive quarterly reports and the service manager meets with the Equality & Involvement Lead monthly.

The annual cost of the service to the Hospital this financial year was £141,947 which

includes the recurring funding of £20,000 received April 2012 from the Scottish Government following the introduction of the Patients Rights Bill; reviewing advocacy provision as a consequence.

2.1 Committee Membership and Role The Board of Directors comprises:

• Keith Swinley, Chairman • Andrew Gardiner, Treasurer

Members:

• Roger Adams • Francis Fallan • Jo Birch • Danny Reilly • Heather Baillie • Margaret Seymour

2.2 Aims and Objectives The Patients’ Advocacy Service aims to provide an independent, highly skilled, responsible and professionally run service within the State Hospital. Whilst observing the safety and security of the Hospital, the Service works independently within it to promote patients as individuals, to support them and to enable them to be fully informed and involved in their care and treatment. 2.3 Meeting Frequency The Board of Directors met 7 times during this year. A working Group on the SLA tender consisting of Board Members and the Service Manager met a further 9 times.

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2.4 Strategy and Workforce The Patients’ Advocacy Service was established in 1997, with the recognition that the patients at The State Hospital are particularly vulnerable and need a mechanism of independent support and assistance that will help them access services and information. The introduction of the Mental Health Care and Treatment (Scotland) Act 2003 specifies the right to access independent advocacy for every person with a mental disorder with a specific mention to the rights of those in the State Hospital. It is vital that the service provided to patients is flexible, efficient, independent and professional. PAS is now completely independent of The State Hospital in-line with Scottish Government legislation and the Scottish Independent Advocacy Alliance Guide for Commissioners; PAS is managed by an Independent Board of Directors. PAS is looking to instruct an independent review of the service in 2015-16 following the successful SLA tender for 2015-2018. PAS provides information, support and assistance to all patients in The State Hospital. Currently PAS has a full time Manager, 3 Advocates (1 full time and 2 part-time), 1 part-time Administrator and 4 Volunteer Advocates. During this financial year we had a vacant post for 10 months, this post has now been filled following the successful tender of the SLA. Management Arrangements The PAS Manager keeps in close contact with the State Hospital’s Equality & Diversity lead and Nursing Director to ensure that there is effective co-ordination with the hospital and that any issues can be dealt with expeditiously. The PAS Manager also attends other relevant meetings in the Hospital including the Equality & Diversity Steering Group and the Child and Adult Protection Forum. 3.0 PATIENT CONTACT Overall Patients had 1952 contacts equivalent to 152 patients Wards – 1389 contacts Skye atrium – 564 contacts equivalent to 89 patients Ward Drop in – Completed 127 throughout the year 3.1 Training Provided initial training and induction to new Staff and new Volunteers Volunteers/Staff attended mandatory training and completed mandatory online modules in TSH that includes Health and Safety, Data Protection and Breakaway. Mental Health Tribunal Training Advance Statement Training Held 2 support/training session for Volunteers and Staff Provided support/supervision to our Volunteers/Staff which also helps to identify any training needs PAS welcomes the opportunity to take part in the training and development offered by the State Hospital, it helps to prepare our new staff/volunteers for the challenges of working in the Hospital and affords the opportunity to develop productive and respectful relationships with State Hospital staff. We actively encourage staff/volunteers and currently we have staff waiting to go on the New to Forensic Training.

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3.2 New Mental Health Act 64 Tribunals attended to support patients 16 Advance Statements completed with the support of an Advocate Support given regarding Named Persons, Advance Statements and Tribunals within the

patient population Assistance to patients to complete Advance Statement Assistance to patients to update existing Advance Statement Assistance to patients to complete applications for Tribunals Supported patients before, during and after Tribunals Ensured that Volunteers/Staff informed about the new Mental Health Act and any changes

We attended 7 Parole Board Hearings, which included meeting with solicitors and assisting patients prepare what they wanted to tell the Parole Board. 3.3 Policies and Procedures All PAS policies and procedures were reviewed and updated during the SLA tender process. 3.4 Participation / Integration PAS staff have participated in a number of State Hospital groups to facilitate and support integrated ways of working that benefit patient care e.g. Equality & Diversity Steering Group, Patient Partnership Group (PPG), Supporting Healthy Choices. PAS has been actively involved in the Supporting Healthy Choices since conception and took part in the evening sessions that visited Hubs to explain what the group was set up to do. Staff participated in a number of groups outside the Hospital, including: the Scottish Independent Advocacy Alliance (SIAA) and Mental Health Tribunal Advocacy Reference Group.

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4 Key Performance Indicators

3 Year comparisons (2012-2013, 2013-2014, 2014-2015)

4.1 Overall Patient Contact 152 patients had 1953 contacts during the year. The number of contacts per patient ranged from 6 patients with a single contact to one patient with 83 contacts (see chart below). The average number of contacts per patient was 13.

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Attendance on wards The Service Level Agreement requires the service to provide a drop in service to each ward once per the graph below shows the number of ward drop-ins throughout the year.

Ward Visits In total, 1389 contacts were made on the wards; this has been broken down into each hub and per ward.

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Skye Centre Drop-in 89 patients were seen accounting for 563 contacts in the Skye Centre. The number of times each patient was seen ranged from 27 patients with one contact to one patient with 66 contacts; average contact 6. The number of contacts has been broken down per month.

4.2 Formal Referral Routes These statistics relate to formal requests for contact with an Advocate (as opposed to informal contact at ward drop-ins, Skye centre drop-ins or community meetings) but are a subset of the overall contact statistics in section 3. 67% of referrals are from patients themselves via the PAS free phone.

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4.3 Patient Referrals Timescales The Service Level Agreement requires that all patients should be seen within 7 working days of referral. The service has been monitoring against a 5 day timescale has achieved the service level agreement, 13 patients were out-with our own target of 5days.

4.4 Issues The service dealt with 2512 issues; 1309 were legal (52% of the total). Hospital issues accounted for a further 7% and quality of life 30%. Of the 67 complaints recorded, 27 formal, 2 informal, 35 resolved locally and 3 not taken forward.

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Case Reviews, CPA and Tribunals The activity classified as legal was associated with supporting patients at formal meetings: case reviews, CPAs and tribunals.

PRELIMANRY WORK It is not just attendance at formal meetings. The preparatory work is substantial and forms part of the support provided during and after the meeting.

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Other significant categories of issues under the legal heading include: Solicitor 175 Parole Board 30 Level of security 23 Police 20 Admission 19 Prison 10

There were 174 hospital issues, the most significant hospital issues were: Patient property 27 Patient’s finance 59 Benefits 20 Hospital policy and procedures 19 Telephones 8

There were 760 Quality of Life Issues the main Quality of Life issues in this heading were identified as: Family and friends 61 Change of ward 49 Outings/Visits out of the Hospital 54 Build Relationship (chat) 54 Information Search 95 Procurement 66

From the remaining categories of issues, the following were the most significant: Complaints 67 Patient health 64 Staff 86 Treatment / medication 52

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Patient Story New Admission admitted from prison with an ongoing Court Case. Initially more concerned with wanting help to prove people lied about him in Court; took a couple of attempts to get him to understand we were “here to help him with his journey through the hospital”. Patient would write 2-3 letters a day complaining about things in the hospital, all about the same things; medication, staff, his court case, letters to solicitor and he struggled to understand that the solicitor would not reply to all his letters and would only visit him when he needed to. Advocacy supported him to raise issues, print off information ie Human rights, help to access medical records, helped him to write letters that were appropriate, help to make complaints, contacted his solicitor and more importantly someone to talk to and reassure him about court case as well as facilitating negotiations with patient and care team regarding his Care & Treatment. Patient now waiting to return to prison. Patient 1 Admission – 6mth Period Staff 1

Attended/Organised Meeting 1

Complaints (Other) 2

Attended CPA 1 Treatment (Other) 2

Complaint (Informal) 1

Advance Statement - Discussion 1

Fill out Forms 1 CPA - Discussion 2

Gathered Information 4

Human Rights Act 1

Letter/Mail 28 Medical Records 1

Local Resolution 2

MWC 1

Phone Call 5 Police 3

Visit/Diary Note 3

Prison 1

Skye Centre Drop-in. 1 Solicitor 4

Adult Protection Support 1

Tribunal - Discussion 2

Totals: 97 Legal (Other) 5

Adult Protection Discussions 2 Treatment/Medication 2 Patient Finance 1 Mail 3 Telephones 1 Change of RMO 1 Family and Friends 4 Physical Aggression from other

patients 2 Smoking 1 Quality of Life (other) 1 Information search 3 Staff (other) 1 RMO 1

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5 COMPARISON WITH LAST ANNUAL REPORT IDENTIFIED AREAS OF WORK ACHIEVED Organisational

Recruit New Staff Member and develop new role.

Advocate started January 2013

Service Continue to develop and review recording system for statistical information focusing on outcomes

Ongoing, changed recording of referrals and added new coding to reflect diversity of work

Continuing to look at patient participation with PAS and involve patients on Board of Directors

Patient representatives in place since October 2010. Currently we are looking for 2 new patient reps so that we can continue meaningful involvement in staff recruitment and all board training.

Continuing a positive relationship and open communication with the State Hospital Board and Hospital staff

Monthly meeting with Equality & Diversity Lead, quarterly reports to Equality & Diversity Steering Group, Annual Report to The State Hospital Board of Directors.

6 AREAS OF GOOD PRACTICE / OUTCOMES DEVELOPMENT Annual patient questionnaire/survey Review of Policies and Procedures completed prior to tender process Regular supervision and annual appraisals of staff/Volunteers Ongoing staff development and training Regular review of Skye Centre drop –in facility Approachable, unbiased and visible service

6.1 Adult Support Investigations Adult Support and Protection legislation supports individuals to raise issues of potential and actual harm to those suffering from mental health problems. PAS has developed a supportive role to patients going through this sometimes difficult process.

Adult Protection Support

0

1

2

3

4

5

6

7

Adult Protection Support 0 2 4 0 1 2

Adult Protection Discussions 1 2 6 4 1 4

May Jun Jul Aug Jan Feb

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6.2 Ethnicity Group Contacts for all Patients between 01st April 2014 – 31st March 2015 This table demonstrates that the service provides support to patients from all ethnic backgrounds equally and continually monitors this.

Ethnic Group Pas Code No of

Patients Percentage No of

Contacts Percentage

Chinese, Chinese Scottish, Chinese

British 3E 2 1.6% 18 0.9% African, African Scottish, African

British 4B 1 0.8% 14 0.7%

White Scottish 1A 95 77.9% 1624 83.2%

White English 1D 3 2.5% 3 0.2%

White Irish 1C 8 6.6% 145 7.4% White Other 1B 10 8.2% 131 6.7%

White British 2A 2 1.6% 1 0.1% Other Ethnic Background 1E 1 0.8% 16 0.8%

Total 122 100% 1952 100.0% 6.3 Outcomes We continue to work towards producing meaningful outcomes from the service we provide for the Hospital and the Patient. In this report we concentrate on Case Reviews, Care Programme Approach Meetings, Tribunals, Parole Board; we have now started to differentiate between Tribunals & Parole Board Hearings. Advance Statements, Wills, information searches and local resolution under the heading “other” give a flavour of some of the pieces of work we do with patients. We are starting to record in the coming year the different meetings we attend with patients i.e. Skye Centre community meeting, Keeping you informed (PPG) “Meeting with solicitors” and will use anonymous Patients stories re contact with PAS.

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TRIBUNALS PATIENT OUTCOME

HOSPITAL OUTCOME TOTAL

Patient knows and understands legal rights and Mental Health Tribunal System

Hospital met legal obligation 82

Patient able to attend meeting independently Hospital met legal obligation 4 Patient felt supported and views made clear through prepared personal statement

Patient supported to attend Tribunal 64

CASE REVIEWS PATIENT OUTCOME


Patient able to express his views/wishes and ask relevant questions Clinical team able to address patients views and questions 287 Patient felt supported and involved (Supported by Advocacy) Hospital met legal obligation 176 Patient able to attend meeting independently Hospital met legal obligation 29

OTHER ACTIVITIES PATIENT OUTCOME


Completion of Advance Statements Patients wishes expressed regarding future care and treatment in a legal document

Future needs identified and patient wishes on how they would be expected to be treated should they become unwell and unable to make decisions regarding their care and treatment

16

Formal Complaints Issues raised and investigated

Local resolution, minimising conflict. Hospital investigate, decision made to uphold or not upheld. Issues can be addressed.

27

Information Search Information gathered due to patient not being able to access internet

Patient able to access information 95 (Average 8pm)

New Admissions Patient understands role of Advocacy, their rights and how to contact us

Hospital met legal obligation 19

Patient supported during meeting Solicitors, Independent doctors, Social Worker etc Patient felt supported during meeting having someone with them to take notes etc

Patient supported to attend meeting. Hospital met legal obligation

46

Local Resolution Patients’ issue resolved through discussions with relevant people and patient

Issues resolved at ward level (Issues/complaints not formally taken forward)

52

Adult protection support Concerns addressed and appropriate action taken

Needs of vulnerable patient addressed independently through adult support and protection investigation

9

CPA Patient able to attend meeting independently

Hospital ensures that the appropriate plans are in place. Statutory obligation

1

Attend CPA Patient involved in care and treatment and future moving on plan

Hospital ensures that the appropriate plans are in place. Statutory obligation

29

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7 FUTURE AREAS OF WORK AND SERVICE DEVELOPMENTS

7.1 Organisational

• Provide 2 training days for Board Members, Staff and Volunteers • Ongoing training for Staff/Volunteers • Complete Annual Report • Organise AGM • Recruit new Staff Member • Recruit new Volunteers • Plan succession for Patient Representatives on PAS Board • Service Planning Day • Plan Independent Review of PAS service

7.2 Service

• Continue to develop improved recording system for statistical information and outcome measures

• Continue to review how we deliver the service • Continue to look at developing patient participation with PAS • Continue monthly drop-ins in all wards • Continue a positive relationship and open communication with the State Hospital

Board and Hospital staff • Patient Survey (questionnaire) for February 2016 • Support the Hospital in meeting the aspirations of The NHS Quality Strategy and

TSH Clinical Model, particularly on the principle of persons continued care.

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FINANCIAL REPORT

Schedule to the Financial Activities For the period from 1 April 2013 to 31 March 2014 £ £ Gross Income 141,957 Gross Expenditure 137,414 4,543 Incoming Resources Government Funding 141,504 Bank Interest 453 141,957 Cost of Charitable Activities Employment Costs 131,851 Establishment Costs 1,359 Print, Post, Stationery 304 133,514 Charitable Donations 100 Governance Costs Accountancy Fees 2,382 Professional Fees 1,169 3,551 Others Total Resources Expended as per Account 137,414 Cash & Bank Accounts 52,767 Liabilities payable in one Year 4,181 Net Current Assets 48,586 9 NEXT REVIEW DATE The Patients’ Advocacy Service Annual Report will be available to The State Hospital Board of Directors from September 2016.

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Date of Meeting: 25 February 2016 Agenda Reference: Item No: 8 Sponsoring Director: Interim Nursing Director Author(s): Training & Professional Development Manager Patient Learning Manager Title of Report: Patient Learning Annual Report 1 SITUATION The attached report provides an update on patient learning services within the State Hospitals Board. It details service activity levels and key achievements for the period January-December 2015. Current challenges and future developments are also highlighted within the report. 2 BACKGROUND Patient learning services within the State Hospital are aimed at: Widening access and participation in learning and education Raising basic standards of literacy and numeracy Increasing skill levels and qualification attainment rates Improving the quality and range of learning opportunities available Reducing barriers to engagement in education and learning Enhancing integration of patient learning and the care and treatment planning process For patients within the State Hospital, participation in education and learning can be an empowering and socialising process and can make a significant contribution to care, treatment and longer-term recovery and rehabilitation. 3 ASSESSMENT Good progress has been made during 2015 to maintain and enhance patient learning services within the State Hospital. The curriculum framework continues to expand, providing increased access to nationally recognised

qualifications and accredited national units. Learning opportunities available range from entry level through to further and higher education and include

clear progression pathways. A number of new programmes and initiatives were successfully implemented. A total of 68 patients engaged in formal learning programmes. 105 formal qualifications were attained within 2015. In relation to the LDP target to support improvement in patients’ educational attainment and life skills through enhancement of literacy and numeracy skills level, there were 20 core skill progressions during 2015. This brings the total number of progressions since the target was introduced in April 2009 to 58 (with 41 progressions in numeracy and 17 in literacy). 4 RECOMMENDATION The Board (Committee) is invited to note the progress that has been made during the past 12 months and to approve the areas for future development detailed within this report.

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MONITORING FORM

How does the proposal support current Policy / Strategy / LDP / Corporate Objectives?

Patient learning services support LDP target to enhance patient literacy and numeracy skills.

Workforce Implications Given the forthcoming retirement of a key staff member within the Gardens activity centre, consideration will need to be given (as part of the recruitment process for this post) to the essential knowledge and skills required to enable ongoing delivery of the horticulture programmes and qualifications and ensure compliance with qualification awarding body standards and requirements. Staff responsible for patient learning programme development and delivery within the different Skye activity centres require dedicated time to be allocate on a consistent and regular basis to support ongoing delivery of current programmes (e.g. time to review and/or create resources) and enable them to progress new developments (e.g. time to develop lesson plans and materials to support the introduction of new qualifications). This resourcing requirement needs to be factored in to operational work plans plus the organisation workforce plan. Additional support/resourcing from eHealth is required to address ICT issues that are currently impacting on patient learning (including upgrading of the patient network, hardware and software; and patient internet access).

Financial Implications Patient learning services are managed within the current allocated budget. Future developments to upgrade the ICT infrastructure that support deliver of patient learning (e.g. upgrading the patient network, replacing hardware, etc) may require additional resources.

Route to the Board (Committee) Which groups were involved in contributing to the paper and recommendations?

Formal reports on patient learning are reported on an annual basis to The State Hospital Board. Key performance indicators associated with patient learning are also monitored on an ongoing basis by the Skye Centre Management Team.


No significant risks identified.


Qualification attainment levels are high and patient feedback in relation to patient learning services and activities is very positive.

Equality Impact Assessment Screened – no issues.

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Patient Learning Annual Report Reference No: Issue: 1 Lead Author: Training & Professional Development Manager Contributing Authors: Patient Learning Manager Approval Group: The State Hospital Board for Scotland Effective Date: January 2015-December 2015 Review Date: January 2016 Responsible Officer: Mark Richards, Interim Nursing Director

Contents Page No 1. Situation

1

2. Background 2.1 Service overview 2.2 Service delivery 2.3 Governance arrangements

1

3. Assessment 3.1 Key Achievements - Core skill screening/assessment - Accredited core skill national units - Toe by Toe basic literacy programme - Open/Distance Learning programmes - Vocational qualifications - Other initiatives - Evaluation of accredited learning programmes

3

3

3.2 Key Performance Indicators - Engagement in Learning - Referrals and leavers - Capacity uptake

- Enrolments and qualification attainments - LDP core skill progression target

11

3.3 Comparisons with previous years

15

3.4 Areas of Good Practice

16

3.5 Identified Issues and Possible Solutions

17

3.6 Future Developments

18

3.7 Financial Implications

18

3.8 Summary

19

3.9 Review Date 19 4. Recommendations

19

Appendices Appendix 1 – Recovery comments

20

1. Situation This report provides an update on patient learning services within the State Hospital. It details service activity levels and key achievements for the period January – December 2015. Current challenges and future developments are also highlighted within the report. 2. Background 2.1 Service overview Education and learning are widely recognised as important elements in promoting individual health and well-being. Key benefits associated with education and learning include improvements in self-confidence and self-esteem, personal development and self-fulfilment, enhanced life and social skills, social inclusion and behavioural change. The following activities fall within the scope of patient learning within the State Hospital: Core skills development (i.e. literacy, language and numeracy) Open and distance learning (including further and higher education) Vocational training (e.g. horticulture, woodcraft, animal care, library and sports) ICT skill development Arts and crafts Personal and social development skills. Although often encompassing an educational component, therapeutic interventions such as psychological or occupational therapies are regarded as outwith the scope of patient learning. 2.2 Service objectives Patient learning services within the State Hospital are aimed at: Widening access and participation in learning and education Raising basic standards of literacy and numeracy Increasing skill levels and qualification attainment rates Improving the quality and range of learning opportunities available Reducing barriers to engagement in education and learning Enhancing integration of patient learning and the care and treatment planning process For patients within the State Hospital, participation in education and learning can be an empowering and socialising process and can make a significant contribution to care, treatment and longer-term recovery and rehabilitation. 2.3 Service delivery Patient learning programmes are delivered within a range of Skye activity centres. This includes: Patient Learning Centre; Patient Library; Skye Access Centre; Gardens & Animal Assisted Therapy Centre; Sports & Fitness Centre; Craft Centre and the Woodcraft Centre. Learning provision includes both accredited and non-certificated programmes and the hospital has ‘approved centre’ status with a number of qualification awarding bodies. This includes the Scottish Qualification Authority (SQA), the British Computer Society (BCS), the Royal Environmental Health Institute of Scotland (REHIS), and Sports Leaders UK.

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The staffing resource within the Patient Learning Centre is detailed in Table A. Table A – Patient Learning Centre Staffing 2015 Post wte Comments Patient Learning Manager (Band 7) 1 Supports activity across the hospital

and wider Forensic Network Senior Staff Nurse (Band 6)

1

Education & Learning Officer (Band 5)

1

Senior Rehabilitation Instructors (Band 5) 1.7 Other 0.3 wte supports weekend activities within Skye Centre

Total 4.7 wte Service delivery within the Patient Learning Centre (PLC) is supported through the use of volunteers, and there are currently 3 volunteers who provide input to the PLC on a sessional basis (totalling 3 sessions per week). Although learning programmes are primarily delivered ‘in-house’, partnership arrangements are in place with several colleges and external training providers, and specialist services and support are sometimes bought in to address gaps in internal expertise (e.g. programme verification for vocational qualifications within gardens; development support for the new qualifications). There is a budget allocation of £6000 to support delivery of patient learning programmes and activities (including all costs associated with qualification approval, candidate registrations, external provider inputs, learning resources, equipment and materials, and staff development). An overview of budget spend for 2015 is provided in Table B. Table B – Budget Spend for Patient Learning Activities 2015 Category £ Awarding body qualification approval costs 50.00 Awarding body registrations/certifications 878.50 Learning resources and materials 2,079.44 External professional support (including internal verification) 1,110.00 Staff development (including assessor qualifications) 1,720.00 Equipment and stationery 189.69 Total costs for 2015 £6,027.63 A fee exemption agreement is currently in place with the Open University (OU) to support patients undertaking OU modules. This is limited to 10 modules per year. Patients undertaking distance learning through other educational establishments are required to self fund (although assistance is provided by the PLC to help patients secure external funding support through ILAs, educational grants, endowment funding, etc where applicable). 2.4 Governance arrangements Senior rehabilitation instructors within each activity centre are responsible for operational delivery of patient learning programmes, and service delivery is co-ordinated and managed by the Patient Learning Manager. Professional leadership and quality management is provided by the Training and Professional Development Manager. Formal reports on patient learning are reported on an annual basis to The State Hospital Board. Key performance indicators associated with patient learning are also monitored on an ongoing basis by the Skye Centre Management Team.

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3. Assessment 3.1 Key achievements during 2015 Details of key achievements and patient learning activities undertaken during 2015 are provided below. 3.1.1 Core skills screening The aim of the core skills screening process is to obtain baseline data on educational ability levels and identify individuals with literacy, numeracy or language development needs. The assessment tool used is the Core Skills Initial Screening Tool developed by SQA. The tool incorporates two assessments (Communication and Numeracy) and maps the individual’s literacy and numeracy abilities against levels 1 - 5 of the Scottish Credit and Qualification Framework (SCQF). During 2015 a total of 56 patients were invited to take part in the core skills screening process. Of this group, 30 patients completed the screening, 17 patients declined to take part at that time, and 9 were unable to participate due to health reasons. Of the 30 patients screened: 5 (17%) were existing patients who had been re-approached after previously being too

unwell to take part or having previously declined to participate. 10 (33%) were patients who were admitted in late 2014. 15 (50%) were new admissions to the hospital in 2015. The screening process has been incorporated within the Skye Centre induction programme and, of the 30 patients who completed the screening in 2015, a total of 15 patients (50%) did so as part of their Skye Centre induction. At 31 December 2015, a total of 106 patients (84% of the current patient population) had been invited to complete the screening process. This is a 2% increase from the previous year. Of the 16% not yet approached, 8% (10 patients) are currently too unwell to participate due to their mental state and 8% (10 patients) have not been approached as they are new admissions to the hospital and have not yet completed their Skye Centre induction. Of the 106 patients invited to participate, 92 patients (87%) had completed the screening process at 31 December 2015. The remaining 14 patients (13%) declined to take part. A breakdown of participation levels by Hub is provided in Figure 1.

Figure 1 : Core Skills Screening - Participation Levels by Hub

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

100%

Arran Iona Lewis Mull

Not Approached

Declined

Too Unw ell

Still to Complete

Completed

Page 3 of 21

The literacy and numeracy screening results for the 30 patients who completed the screening process in 2015 are provided in Figure 2a and 2b.

Figure 2A: Literacy Screening Results

< Level 20%

0%

Level 210%

Level 353%

Level 4 or above37%

Figure 2B: Numeracy Screening Results< Level 2

0%

0%

Level 228%

Level 317%

Level 4 or above55%

As indicated in Figure 2a and 2b above, of the 30 patients screened in 2015: 90% have literacy skills at the functional level of Level 3 or above 72% have numeracy skills at the functional level of Level 3 or above 0% (i.e. no patients) screened below Level 2 in either literacy or numeracy. Details of the literacy and numeracy assessment results for the total current patient population who have completed the screening process are provided in Figure 3a and Figure 3b below.

Figure 3A : Literacy Screening Results

< Level 24%

Level 214%

Level 344%

Level 4 or above38%

Figure 3B : Numeracy Screening Results

< Level 23% Level 2

24%

Level 321%

Level 4 or above52%

In summary, of the total patient group screened: 82% have literacy skills at the functional level of Level 3 or above 73% have numeracy skills at the functional level of Level 3 or above When compared to screening results from 2014, the number of patients with literacy skills below Level 3 has decreased by 5% to 18%. This remains slightly higher than reported literacy deficits within the general population (where deficits are estimated at 16%). The number of patients with numeracy skills below Level 3 is 27% a 3% decrease from 2014. This again is slightly higher than the national average (estimated at 24%).

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3. 1.2 Core skill national qualifications Core skills are a key component of the national education and lifelong learning strategy. They represent the broad, transferable skills that help to develop the main capabilities that people need to participate as full and active members of society. They underpin the adult literacy and numeracy strategy and the core skill framework aims to develop key skills in the areas of: Communication Numeracy Information technology Problem solving Working with others Individuals can gain credit for achieving core skill national units at different levels, and core skills can be assessed at levels 2-5 of the Scottish Credit and Qualification Framework. During 2015, there were 52 core skill completions - an increase of 5 from the previous year. A breakdown of completions, by subject and level, is provided in Figure 4.

Figure 4 - Core Skills Completions (Jan 2015 - Dec 2015)

0123456789

1011121314

Level 2 Level 3 Level 4 Level 5

Communication

IT

Numeracy

Working WithOthers

73% of the core skill qualifications obtained in 2015 were undertaken at Level 3 or above, compared to 34% in 2014. This indicates that learners are completing higher level qualifications and also highlights increased learner progression (a point which is evident in the LDP targets detailed in section 3.2.3 of this report). It is useful to highlight that a number of the core skill qualifications were completed through group learning programmes delivered within the Patient Learning Centre. Several new computing courses were delivered to support delivery of ICT core skills, as well as themed learning programmes on Scottish Heritage and the Natural Wonders of the World. The themed learning programmes were each run over a 10 week period and the patients who took part all completed core skill qualifications in Communication. The ‘Working With Others’ core skill qualification was delivered for the first time during 2015 and a group of 5 patient library assistants completed this qualification at Level 3 whilst undertaking a library “work” task together as a team. The patients enjoyed working with their peers and the programme allowed them to develop essential communication and team working skills. This work-based model of delivery will be extended in 2016 to incorporate the ‘Problem Solving’ core skill units, and 4 core skills will be integrated within the vocational training programme (excluding numeracy) that is delivered for patients undertaking the library assistant volunteer role.

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In addition to the 52 unit completions achieved in 2015, a further 16 core skill units are currently in progress (i.e. patients are working towards completion). A breakdown of these units, by level and subject, is provided in Figure 5.

Figure 5 - Core Skills in Progress

0

1

2

3

4

5


CommunicationITNumeracyProblem Solving

Of the 16 ongoing qualifications, it is worth highlighting that 1 patient is undertaking the ‘Problem Solving’ qualification which was only introduced in 2015. A total of 255 core skill units have now been completed since the qualifications were introduced in October 2007. A breakdown of completions, by subject and level, is provided in Figure 6.

Figure 6 - Core Skills Completions (2007 - 2015)

05

10152025303540455055


Communication

IT

Numeracy

Working WithOthers

3.1.3 ‘Toe by Toe’ basic literacy programme The ‘Toe by Toe’ reading scheme continues to be employed to support patients with significant literacy deficits (i.e. below Level 2). ‘Toe by Toe’ is aimed at non-readers and those with poor reading abilities. It is a highly structured multi-sensory reading system delivered via one-to-one tuition. Learning sessions take place five times a week, for up to 20 minutes per session, for an average duration of 6 months.

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During 2015 a total of 4 patients engaged in the Toe by Toe programme. Uptake was low and as of 31 December 2015, only 2 patients remained on the programme (as 1 patient had transferred and 1 withdrew from the programme as they did not wish to continue with this learning). Progress for patients undertaking the programme was limited, due to low motivation and interest among the participants, and staff resource pressures at times had an impact on the number of 1-1 sessions that could be delivered. Patients participating in the programme were supported by the PLC to undertake additional literacy interventions to help improve overall literacy and communication skills (e.g. writing, speaking and listening skills). Patient feedback on these interventions was very positive and consideration is currently being given to the introduction of a basic skills group to support patients with lower level literacies issues. 3.1.4 Open/distance learning programmes During 2015 a total of 9 patients participated in open/distance learning programmes (with 7 continuing their studies from the previous year and 2 patients commencing this type of learning for the first time). A total of 24 modules were undertaken. Eight of these modules were ongoing from 2014 and the remaining 15 were new enrolments. At 31 December 2015, 12 modules were complete, 10 are ongoing, 1 patient has transferred to medium security, and one module was withdrawn as the patient did not complete the course. Details of the range of modules that were undertaken in 2015 are provided below: Course Provider Enrolments

in 2015 Status

Introduction to Sport, Fitness & Management

Open University N/A 2 Completed

Bon Depart: Beginners French Open University N/A Completed Law: Ownership & Trusteeship – Rights & Responsibilities

Open University N/A Completed

Creative Writing Open University N/A Completed Portales: Beginners Spanish Open University N/A Withdrawn Introducing the Social Sciences Open University 1 1 Completed

1 Ongoing Discovering Mathematics Open University 2 2 Completed

2 Ongoing Introduction to Business Studies 1 Open University 1 Ongoing Essential Mathematics Open University 1 Transferred to

medium security Investigating the Social World Open University 1 Ongoing Journeys Through a Changing World Open University 1 Ongoing Working & Learning in Sports & Fitness Open University 2 Ongoing Investigating Psychology Open University 1 Ongoing Batchelor of Laws (1st class honours degree) Open University 1 Completed Capital 1 London University 1 Completed Capital 2 London University 1 Ongoing Corporate Management 1 London University 1 Completed Corporate Management 2 London University 1 Completed

It is useful to highlight that each Open University module that is undertaken involves approximately 30 weeks of intense study by each learner. Given the study demands, the patients undertaking OU modules attend the PLC for at least 4 sessions per week.

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As well as studying the diverse range of subjects detailed in the table above, patients who are undertaking open/distance learning are developing additional skills such as effective study techniques, time management and organisational skills, problem solving skills, improved concentration and confidence, and are developing effective coping strategies relating to managing the demands associated with undertaking higher level academic study. This is particularly evident for patients who are now undertaking their second year of studies. During 2015, one patient successfully completed a Bachelor of Laws 1st Class Honours Degree with the Open University – having completed 8 modules over a 5 year period within the hospital. It is also worth highlighting that the patient who transferred to medium security has successfully continued his learning with support from the PLC staff. 3.1.5 Vocational qualifications A total of 10 vocational programmes were delivered during 2015 and 38 vocational qualifications were successfully achieved. The programmes were delivered across a range of activity centres and details of the programmes offered, qualification achievements, and projected activity for 2016 are summarised in Table C. The Woodcraft Centre gained SQA approval in 2015 to deliver a ‘Practical Woodworking’ qualification at National 4 and 5 Level. The qualification comprises 3 units and a practical woodworking project, and a group of 5 learners commenced the programme in October 2015. The programme takes 9-months to complete. The learning is highly practical and provides patients with nationally recognised and transferrable work-based skills and qualifications in woodcraft. The hospital also obtained ‘approved centre’ status with Sports Leaders UK in 2015 and gained accreditation to deliver the Sports Leadership Award. This qualification has previously been delivered through a sub-contractor arrangement with a local college. Gaining approved centre status has enabled staff within the Sports and Fitness centre to deliver the programme internally, as well as increasing flexibility in relation to programme scheduling and supporting the development of the rehab staff who deliver this award. The overall number of vocational qualifications achieved in 2015 decreased by 28 compared to the previous year. The key reasons for this are noted below. Horticulture qualifications – The Maintaining Safe & Effective Work Practices Intermediate

Level 1 unit and the Horticulture Level 1 SVQ were withdrawn from the SQA portfolio and these qualifications are no longer available. In addition, the Soft Landscaping Intermediate Level 1 unit was not delivered in 2015 due to capacity issues within the Gardens Activity Centre.

Introductory food hygiene qualification – A large number of patients have now completed this training and demand for this qualification was low in 2015 - with course enrolments down by 11 (from 15 participants in 2014 to 4 participants in 2015).

Small animal care qualification – A large number of patients who currently attend sessions

within this activity centre have now completed this programme and demand for the qualification was subsequently low in 2015 - with course enrolments down by 7 (from 10 participants in 2014 to 3 participants in 2015).

European Computer Driving Licence (ECDL) – Ongoing issues with regards internet access have meant that patients are currently unable to complete the full ECDL qualification. Some patients continue to undertake individual units within the programme as stand-alone qualifications, however, achievement levels are down 5 (from 9 unit completions in 2014 to 4 unit completions in 2015).

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Table C – Vocational Programmes & Qualification Achievements

Qualification /Awarding Body

Activity centre/ area delivering award

Date Award Approved

Achievements in 2015

Total no of completions since approval of award

No of patients currently working towards award

New enrolments planned for 2016 with expected start dates

Practical Tasks for Information and Library Work – Intermediate level 1 (SQA)

Library (Atrium)

2011 1 9 3 Available as required for new pt. volunteers

Sports Leadership Level 1 Award (Sports Leaders UK)

Sports 2012 6 16 0 6 (Oct 16)

Small Animal Care Unit – Intermediate level 1 (SQA)

Gardens & AAT Centre

2009 3 42 0 5 (Feb 16)

Soft Landscaping Unit – Intermediate level 1 (SQA)


2011 0 8 0 No courses scheduled

Laying Slabs and Paving unit – intermediate level 1 (SQA)


2013 4 7 3 Course currently in progress

Horticultural Fence Construction – intermediate level 1 (SQA)



Use of hand tools in horticulture – intermediate 1 (SQA)



Practical Woodworking – National 4/5 (SQA)

Woodcraft Centre

New in 2015

0 0 5 Course currently in progress

Introductory Food Hygiene Certificate (Royal Environmental Health Institute for Scotland)

Patient Learning Centre/ L&D

2010 4 63 0 2 courses to be scheduled for 2016.

Elementary Food Hygiene Certificate (Royal Environmental Health Institute for Scotland)

Patient Learning Centre/ L&D

2012 10 31 0 1 course to be scheduled for 2016.

European Computer Driving licence (ECDL) - accredited modules (British Computer Society)

Patient Learning Centre

2011 4 53 1 Available on demand

ECDL - full award (comprises 7 accredited modules) (British Computer Society)



Advanced ECDL – accredited modules (British Computer Society)



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3.1.6 Other initiatives Other programmes and learning initiatives that were delivered in 2015 include: ‘Bikeability’ cycling proficiency programme – The Sports and Fitness Centre successfully

developed and delivered the national ‘Bikeability’ programme during 2015. This is a national training scheme and aims to increase skills and confidence to cycle safely and carry out simple bike safety checks. The programme is delivered over a 4-6 week period and in 2015 a total of 9 patients participated and achieved the certificate.

Short courses – A range of short-courses were delivered within the Woodcraft and Craft activity centres during 2015. These included ‘Introduction to Painting & Decorating’, ‘Introduction to Pottery’, ‘Advanced Pottery’ (newly introduced), and themed craft groups for Halloween and Christmas. The short courses were each delivered over a set duration of 8 or 9 sessions and a total of 21 patients participated in the programmes available. All of these short courses are highly practical and patients were able to exhibit the craft items which they had created within the courses at the ‘Celebration of Achievement’ learning ceremony that was held in October 2015.

3.1.7 Evaluation of accredited learning programmes A new Learning Evaluation Questionnaire was developed during 2015 to obtain patient feedback on learning programmes that were undertaken and identify what benefits they felt they had derived from their participation in learning and education. The questionnaire was implemented in August 2105 and has been used within all programmes completed from August onwards. As of 31 December 2015, at total of 28 patients had completed the questionnaire after obtaining qualifications within the following programmes - Core Skill National Qualifications (including communication, ICT and numeracy), Practical Tasks in Library & Information Work National Qualification; Sports Leadership Award, and ECDL. A summary of how the patients rated different aspects of programme delivery is provided in the Table D below. Table D – Learner feedback Areas covered Very

Satisfied Satisfied Dissatisfied Very

Dissatisfied

Induction to learning programme

79% 21% 0% 0%

Information given about qualification

71% 29% 0% 0%

Information given about assessment process/outcomes of learning

71% 29% 0% 0%

Information given about your responsibilities

75% 25% 0% 0%

Access to support and guidance from tutor/instructor

82% 18% 0% 0%

The pace of learning

71% 29% 0% 0%

The learning methods and resources used

75% 25% 0% 0%

Opportunities to discuss and review learning

75% 25% 0% 0%

Assistance to address any problems experienced during learning

71% 29% 0% 0%

Overall Satisfaction

75% 25% 0% 0%

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It is important to note that all patients were either ‘Very Satisfied’ or ‘Satisfied’ across all areas of programme delivery. It is also worth highlighting that 82% of respondents reported that they were ‘Very Satisfied’ with the support and guidance provided by their tutor/instructor. This is testament to the dedication and commitment of the Skye Centre staff who deliver the qualifications across the different activity centres. Patients were also asked within the questionnaire to identify how they found out about the learning programme they had undertaken. The feedback was as follows: 24 patients – information provided by Skye Centre / activity centre staff 3 patients – information provided by key worker / ward staff 1 patient – information obtained from the Patient Guide to Therapies & Activities As indicated above, the majority of patients found out about patient learning opportunities from Skye Centre staff. It is encouraging, however, that one patient reported having found out about the learning opportunity from the ‘Patient Guide to Therapies and Activities’, which was a new document that was only launched in October 2015. As part of the evaluation questionnaire, patients were also asked to identify what benefits they felt they had gained from their participation in the learning programme. The key reported benefits included: improved knowledge and skills (in the area of study); feeling encouraged to do more learning; improved concentration; personal satisfaction/sense of achievement; improved confidence; personal enjoyment; and opportunities to work with others in groups. Patients were also invited to take part in a short survey that was undertaken as part of the ‘Celebration of Achievement’ event held in October 2015. They were asked to give feedback on the following question - ‘How has learning helped with your recovery?’. A total of 35 patients took part and the key reported benefits included: • Improved concentration • Focus (keeps mind off other things) • Future aspirations/potential to learn more • Sense of achievement/feel valued/sense of purpose • Feel better/improved mood/happier/well being • Improved confidence/motivation • Enjoyment • Improved self-esteem Full details of the responses provided by all 35 patients who took part in the survey are included for information in Appendix 1. The reported benefits link closely with the key themes identified from the learning evaluation questionnaire. Whilst there are no standard tools available nationally to measure the impact of learning on mental health recovery, it is evident from the feedback obtained that patients in the State Hospital value learning and believe it supports their recover and well-being. 3.2 Key performance indicators Key performance data relating to patient learning services and activities for the period January – December 2015 is provided below.

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3.2.1 Participation levels a) Engagement in learning During 2015, a total of 68 patients within the hospital engaged in formal accredited learning. This equates to 54% of the total patient population and 69% of the patient population who attend Skye Centre placements. Of the 68 patients who participated in accredited learning, a total of 47 patients (69%) attended the Patient Learning Centre over the course of the year. It is also worth noting that 25% of the patients who attended the PLC had between 3-7 placements in the centre per week due to the nature of the learning programme they were undertaking. Although the total number of patients who participated in accredited learning during 2015 reduced by 9% when compared to the previous year, it is important to highlight that the number and level of qualifications being undertaken by the individual patients has actually increased (i.e. individual patients engaged in more programmes and attained more individual qualifications throughout the year). A breakdown by Hub of patients who engaged in formal learning during 2015 is provided in Figure 7.

Figure 7 : Total Learners by Hub

0

5

10

15

20

25

Arran Iona Lewis Mull

b) Referrals and leavers There were 24 new referrals to the Patient Learning Centre during 2015, an increase from the previous year. Of this total:

• 15 started a placement in PLC • 4 are commencing a placement in January 2016 • 2 were discharged prior to starting their placement within the PLC • 2 refused to start

In addition, a total of 13 patients ceased attendance at the Patient Learning Centre in 2015. The reasons for leaving are noted below.

Page 12 of 21

• 8 transferred to other hospitals • 2 achieved their planned learning outcomes • 2 voluntarily withdrew from their learning programme • 1 was unable to attend due to a deterioration in their mental health

It is worth highlighting that for patients who transfer to other facilities the PLC staff have worked in partnership with staff in the receiving facility to ensure that patients are supported to continue their learning following transfer. c) Capacity uptake The Patient Learning Centre is open 8 sessions per week. During 2015 there were 10 unscheduled closures, which is a significant decrease from the previous year (with 27 fewer closures). It is worth highlighting, however, that whilst the unscheduled closures were significantly reduced the PLC did run a reduced service on 12 sessions within the year (i.e. they delivered the session but with less patients attending than were planned). These ‘reduced service’ session, plus 4 of the 10 unscheduled closures, were due to staffing resource issues within the PLC or other Skye activity centres. Planned attendance within the Patient Learning Centre during 2015 was equivalent to a capacity uptake level of 96% (an increase of 3% from 2014). Actual uptake of placements was 83% (which was unchanged from the previous year). The primary reason for the variation between planned and actual capacity uptake was patient non-attendance. During 2015 there were 625 incidents of non-attendance (a 12% increase from 2014). A summary of the reasons for non-attendance are detailed in Figure 8. Comparative data from 2014 has also been provided.

Figure 8 : Reasons for Non-Attendance

0

20

40

60

80

100

120

140

160

Appt

s e.

g. R

MO

,de

ntis

t, G

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tate

Phys

ical

Con

ditio

n

Oth

er A

ctiv

ities

(In S

kye

Cen

tre)

Oth

er A

ctiv

ities

(In H

ubs)

Gro

up T

hera

pies

(Psy

chol

ogy,

OT)

Patie

nt R

efus

al

Visi

ts

Atte

ndin

g PP

G

Mis

cella

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s

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iew

s/Tr

ibun

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Solic

itor V

isit

Out

ings

/Ext

erna

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poin

tmen

ts

Cou

rt

2014

2015

During 2015, the main reasons for non-attendance within the PLC were attendance at psychological therapies, deterioration in mental state, and physical health issues. These categories combined accounted for 48% of non-attendance.

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There was a significant increase in non-attendance due to attending psychological therapy groups, however, non-attendance linked to attending other activities in the Skye Centre decreased in 2015 and reflects improvements to the planning of Skye Centre activities that have results from development of the curriculum timetable. (This latter activity is part of the patient day project.) 3.2.2 Course enrolments & qualification attainments Figures for course enrolments and qualification attainment levels (e.g. accredited core skill units, vocational qualifications, and open/distance learning module completions) for 2015 are provided in Figure 9. Comparative data from previous years has also been provided.

Figure 9 : Enrolments and Qualification Attainment (2007-2015)

0

20

40

60

80

100

120

2007 2008 2009 2010 2011 2012 2013 2014 2015

Enrolments

Qualification Attainment

As evident in Figure 9, qualification enrolments are comparable to 2014 and there has only been a slight decrease in achievements. Attrition rates remain very low and for 2015 were below 5%. 3.2.3 LDP core skill progression target In relation to the Local Delivery Plan (LDP) target to enhance basic literacy and numeracy skills by increasing the number of patients with core skills at Level 3 or above, a total of 20 core skill progressions were achieved during 2015 (an increase of 11 from 2014). Details of the progressions are noted below:

• 7 patients progressed from level 2 to level 3 in numeracy • 5 patients progressed from level 3 to level 4 in numeracy • 2 patients progressed from level 4 to level 5 in numeracy • 3 patient progressed from level 2 to level 3 in literacy • 3 patient progressed from level 3 to level 4 in literacy

This brings the total number of progressions to 58 (with 41 progressions in numeracy and 17 in literacy). A further 8 patients are currently working towards completion of higher level core skills (Level 4 in numeracy x 5 patients and Level 4 in Communication x 3 patients). Five patients have also achieved progressions in IT core skill qualifications.

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3.3. Comparisons with previous years Based on the performance data presented in sections 3.1 and 3.2 of this report, key comparisons with performance for the previous four years is summarised in the Table E below. Table E – Performance Data 2011-2015 PERFORMANCE DATA

2011

2012

2013

2014

2015

Percentage of patients invited to participate in core skills screening

87% 83% 91% 82% 84%

Percentage of patients who have completed the screening process

70% 78% 82% 88% 87%

Percentage of patients with identified literacy deficits (i.e. <Level 3)

23% 22% 27% 23% 18%

Percentage of patients with identified numeracy deficits (i.e. <Level 3)

40% 33% 30% 30% 27%

Number of new referrals to Patient Learning Centre

24 25 32 20 24

Number of leavers from Patient Learning Centre

22 10 32 25 13

Patient Learning Centre closures (unscheduled)

42 21 28 37 10

Episodes of non-attendance within Patient Learning Centre

743 785 565 559 625

Capacity uptake within Patient Learning Centre

77% 77% 86% 83% 83%

Percentage of patients who participated in formal accredited learning

42% 45% 63% 63% 54%

Course enrolments

52 101 93 114 113

Course completions / qualification attainments

17 84 63 117 105

Core skill progressions (LDP target)

3 2 9 9 20

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3.4. Areas of good practice Areas of good practice identified for 2015 are outlined below. Partnership working with Open University (OU) – Delivery of distance learning

programmes has increased significantly within the hospital over the past 2 years. Support for patients participating in distance learning programmes is provided by staff within the PLC. Our learner achievement rates in 2015, at 89%, were the highest rate achieved across all secure facilities in Scotland (including prisons and young offender facilities). Factors that contributed to these high achievement rates included: commitment from patients and consistent attendance at the PLC throughout their 30 week programme; support from staff within the PLC to facilitate learning and encourage and motivate patients to meet learning and coursework submission deadlines; highly responsive support from the OU learning support team and ongoing input from OU tutors through visits, telephone tutorials and emails. The PLC team have developed excellent links with staff from the OU and this has helped to ensure that patients have an effective learning environment and receive a high level of support.

SQA ‘approved centre’ quality audit – A systems verification audit was undertaken by the Scottish Qualifications Authority in October 2015 to assess the hospital’s quality systems and processes linked to delivery of SQA accredited qualifications and ensure compliance with SQA quality standards and programme requirements. The audit results were extremely positive and we received a ‘significant strengths’ rating for all 33 quality criterion set out within SQA’s Centre Quality Framework. To achieve a ‘significant strengths’ rating across all 33 separate criterion is a major achievement and the auditor advised that the hospital was the first centre audited to have achieved this level of performance against the new SQA standards. This demonstrates that the staff involved in patient learning are following best practice and working to very high standards. This is reflected in achievement levels and in the feedback received from patients, and shows that patient learning provision within the State Hospital is of a high quality.

Development of links/information sharing across the Forensic Network – The Patient Learning Manager set up a working group across the network during 2015 to explore the recommendations from a scoping exercise on patient learning that was carried out the previous year. The group are currently exploring how we can develop a standardised approach for undertaking initial assessments and literacy/numeracy screening. Group members are finding the support and opportunity to share ideas beneficial and a key aim of the group is to help make the ‘learning journey’ seamless when patients transfer across facilities. The Patient Learning Manager is also currently involved in reviewing what patient learning information could be incorporated into the discharge process to ensure that all relevant information is transferred from the hospital to the receiving units. This piece of work is being led by the clinical effectiveness team and it is hoped that this will be completed by April 2016.

Introduction of a new Patient Guide to Therapies & Activities – This new guide contains information on the full range of therapies and activities that are currently available within the hospital. Production of the guide was an extensive piece of work and involved all disciplines working collaboratively to identify and document the activities that were offered within each department. The guide aims to support increased patient engagement in meaningful activity activities and provides patients and staff with a single source document which they can refer to and use when discussing patient needs and planning care and treatment interventions and referrals.

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3.5. Identified issues and potential solutions As indicated previously, good progress was made during 2015 to further enhance and maintain patient learning provision within the State Hospital. Several new developments and activities planned for 2015 were unable, however, to be progressed due to capacity and staffing resource pressures within the Patient Learning Centre and across other Skye activity centres. Key contributory factors have included: Sickness absence levels within the Skye Centre during 2015. This results in movement of

staff between activity centres (to provide staff cover in other areas), and activity centres being resourced with minimum staffing levels. This has resulted in limited availability of suitably qualified and experienced technical staff to progress new developments within activity centres.

Loss of key staff due to retirements and staff leaving the organisation, again limiting the

availability of suitably qualified and experienced staff. The Education & Learning Officer post within the PLC was vacant for over 12 months, with the new post holder only commencing in post in September 2015. This lengthy vacancy restricted the number of developments that could be progressed and also impacted on delivery of some learning activities within the PLC as the remaining staff within the centre did not have the relevant ‘technical’ skills to deliver elements of some programmes.

Limited planning and development time for staff which limits capacity to develop new programmes and associated learning materials and resources, etc. Some progress has been made in 2015 to ensure provision of ‘ring-fenced’ programme planning and development time for key staff, however, ongoing commitment and resourcing is required to ensure that dedicated planning and development time is available on a consistent basis throughout the year.

No dedicated eHealth resource to maintain and develop the patient network and support other ICT developments relating to patient learning. The support available from eHealth has been ad hoc and reactive – providing short-term fixes for technical faults but not addressing longer-term issues or service developments. The software being used within the patient learning centre is outdated and the current patient network and general ICT infrastructure is in a fragile condition. Expansion of internet access has also not been progressed. This is an ongoing issue that impacts on service quality and restricts access to learning opportunities and programmes. Given that IT literacy is now fundamental to modern life it is also denying patients the opportunity to develop these essential life skills. The Head of eHealth has advised that due to other priorities and work demands within eHealth, ICT projects relating to patient learning cannot be progressed without securing dedicated staff resource to manage these projects. It is also important to highlight that future developments are dependent on eHealth securing additional resources to upgrade and enhance the patient network.

In addition to the above, it has also been identified that a key member of staff within the Gardens activity centre is due to retire during 2016. It is essential that consideration is given, within the recruitment process, to the experience and technical skills required to deliver the range of qualifications that are offered within this department and that recruitment is undertaken timeously to ensure that programme delivery can be maintained. The Skye Centre Management team is fully aware of the above issues and throughout the year has taken steps to minimise the impact on patient learning activities. It is also anticipated that the introduction of the ‘CELCAT’ timetabling software within 2016 will result in improved planning and deployment of resources and assist in helping to address some of the resource and capacity issued identified within this report.

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3.6. Future developments Maintaining, revising and expanding patient learning programmes and opportunities will continue to be a major focus in 2016. This will be undertaken in line with the ethos and objectives of the national Curriculum for Excellence and key objectives for the year ahead include: Ongoing expansion of vocational learning programmes through supporting the Craft

Centre to identify, develop and gain approval for a suitable Craft qualification. (Completion target October 2016).

Support staff delivering new qualifications to obtain the SQA assessor qualification. For 2016, this will target staff within the Gardens and Woodcraft vocational areas to develop internal capacity to sustain delivery of qualifications and to ensure compliance with awarding body requirements. (Completion target September 2016).

Ongoing delivery of short courses, taster programmes, themed events and group learning programmes – The Patient Learning Centre will deliver 2 themed learning programmes during 2016 on the topics of the ‘Holocaust’ and ‘European Football Championships’. Core skill qualifications will be embedded within these themed learning programmes. Additionally, the ‘Reading Ahead’ national programme will be delivered through the Patient Library to promote reading and support ongoing enhancement of literacy skills. (Completion target December 2016).

Liaison with the Skye Centre Manager to ensure that recruitment to the Band 5 Senior

Rehabilitation Instructor post within the Gardens activity centre is progressed timeously to minimise disruption to service delivery and to ensure that consideration is given, within the recruitment process, to the experience and technical skills required to deliver the range of qualifications that are offered within this department. (Completion target September 2016).

Ongoing liaison with the Head of eHealth to explore solutions to address the current ICT issues and secure required resources to enable ICT projects for patient learning to be progressed.

All future developments will give cognisance to the recommendations and outcomes from the Patient Day project. 3.7. Financial implications Implementation of the developments planned for 2016 will depend, in part, on the resource issues highlighted in section 3.5 being successfully addressed. Dedicated time needs to be provided for staff responsible for programme development and delivery across the range of activity centres to sustain the current services/activities offered. Time also needs to be provided to enable further development and up-skilling of key staff to ensure they are equipped with the knowledge and skills required to support ongoing curriculum expansion and delivery of the service priorities identified for patient learning. Resourcing requirements associated with addressing and progressing the ICT issues highlighted in section 3.5 also need to be clarified and steps taken, in conjunction with the Head of eHealth and the Skye Centre Manager, to secure additional resourcing to enable progress in this area.

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3.8 Summary In summary, ongoing progress has been made during 2015 to maintain and enhance patient learning services within the State Hospital. The curriculum framework continues to expand, providing increased access to a range of nationally recognised qualifications and accredited learning programmes, and a high number of attainments are now being achieved each year. Despite the ongoing challenges that were encountered during 2015, significant progress has still been made to maintain services and enable enhancement of patient learning services and activities within the State Hospital. This can be attributed, at least in part, to the continued dedication and commitment of staff within the Patient Learning Centre and other Skye activity centres. 3.9. Review date The next review date for patient learning services is January 2017. 4. Recommendations

The Board is invited to note the progress that has been made during the past 12 months and the areas for future development detailed within this report.

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Appendix 1

Comments from patients about ‘How has learning helped with your recovery?’

35 responses 1. “Learning percentages, fractions and algebra operations has helped my recovery by giving me

back my self-esteem and making me think very seriously about taking up education back in the community again”

2. “It has taken my mind off any problems I have and I feel as if I am achieving something” 3. “Getting off the wards, being able to sit down and relax. It takes my mind off my troubles and

helps me feel better about life in general” 4. “Learning has helped with my recovery because I have mixed with new folk and helped my

concentration skills and helped with my bipolar and moods” 5. “The Patient Learning Centre has helped me with confidence. When I first came in to the

hospital I felt really depressed and introverted. When I first attended the learning centre the staff in the ward and the clinical team noticed a huge difference in my self confidence and the more I learned the more I wanted to learn”

6. “It’s given me more focus, it makes me happier and I also liked learning new skills” 7. “Enabled me to focus and concentrate my mind and given me something else to think about

other than mental illness” 8. “It has improved my concentration and I can overcome stressful situations with a degree of

success. 9. “Keeps my mind off things and keeps me off the ward” 10. “Regained control of concentration which was shot. Felt ‘valued’ as a member of society once

more. The opportunity to use time constructively” 11. “A great feeling of achievement” 12. “It has gave me a great focus. I have had a brilliant sense of achievement. It has given me a

positive purpose for using my time and energy” 13. “Concentration levels have improved, self confidence has increased. I feel more confident in

my capabilities in a goal orientated scenario” 14. “Sense of achievement. Helped concentration and well being and improved confidence. It has

distracted me from worrying thoughts”

15. “It has helped free me from worrying about things and gained in concentration levels, given me confidence in myself”

16. “It has given me focus, direction, a challenge. A sense of achievement and a source of

enjoyment”

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17. “When I came into the hospital I was a nervous wreck. I did not eat or drink anything and I had severe depression. My life was just one gigantic car crash with no cure in sight. But when I joined the PLC I found a way out of my problems and I buried myself in my work, which now I enjoy very much. My teachers are great and I hope I can continue my work and move onto better things”

18. “Mostly with motivation and confidence” 19. “Improved concentration. Gave me structure to my day. A sense of purpose and awareness of

potential” 20. “To cope with my mental health” 21. “Learning has definitely helped with my recovery. It relaxes me and gives me a boost every

time I finish a course or gain a qualification” 22. “I have learned how to boost confidence, self esteem and also concentration” 23. “Improved concentration” 24. “It keeps my mind off things” 25. “It has helped me be positive and take my mind off things” 26. “I understand about triggers which can help me identify if I’m becoming ill again” 27. “More confidence, improvement in communication skills, more faith in own abilities, motivated

to undertake new courses” 28. “Improved my concentration and self-esteem” 29. “It has helped me set small goals for my future and made me realise that I still can learn new

skills as well as improving old ones. I have an improved sense of ‘me’ and my concentration is slowly but surely improving”

30. “It has helped develop my knowledge which in turn has boosted my confidence and self

esteem. Made me realise that I can actually concentrate for longer on tasks instead of being ‘bogged down’ by my illness and symptoms”

31. “Improved my sense of well being, made me more positive about the future and helped my

concentration” 32. “It has enabled me to concentrate better and for longer. It has helped me focus on something

else apart from mental illness” 33. “Concentration has improved, sense of worth has increased, it’s made me realise that I can

achieve qualifications” 34. “Improving my math’s skills has made me feel better about myself and has made me feel more

confident” 35. “It has helped me to understand things more clearly”

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 25 February 2016 Agenda Reference: Item No 11 Sponsoring Director: Human Resources Director Author(s): Human Resources Director Title of Report: Organisational Values and Behaviours 1 SITUATION Organisational values and behaviours are the very touchstone upon which we are viewed and measured not only by the patients for whom we provide services, their relatives and carers but also by our own staff. It is well evidenced that organisations which demonstrate that they operate in line with their stated values and expected behaviours see the benefit in many ways. This includes increased staff engagement and the provision of high quality services to patients. 2 BACKGROUND The 2020 workforce vision was launched in June 2013. It detailed the values that are shared across Scotland’s Health Services, and which have been adopted within the hospital, as being:

• Care and Compassion • Dignity and Respect • Openness, honesty and responsibility • Quality and Teamwork

In addition to this it is expected that Board’s will embed these values in everything that we do to ensure that the 2020 Vision becomes a reality and more importantly is seen by patients and staff as the way in which we conduct our day to day business. 3 ASSESSMENT Both the feedback from the Staff Survey (2015) and the iMatter Board report (2015) have indicated that we need to consider the values and behaviours within the hospital in relation to how staff perceive the organisation overall and also how staff interact with each other whilst in the workplace. Feedback from patients is received via the Patient Involvement framework within the hospital which is extremely effective at collating this information. It is important that patients and carers believe and see in our daily business that the patient is at the centre of everything that we do. Staff also need to feel valued and seen as an essential and equal member of the team empowered to work to the best of their ability. They also have the responsibility to act and behave to patients, relatives and work colleagues in an acceptable manner.

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To ensure that the 2020 vision becomes a reality some of the things that we need to do include:

• Putting the Staff Governance Standard into practice in all that we do • Ensuring that everyone is clear about the values and behaviours expected of them and that

our stated values are put into practice • Empowering teams and individuals to innovate and make things better • Nurturing and developing team working and professionalism • Employing people who demonstrate our core values by improving recruitment practices • Recognising the achievements and efforts of individuals and teams • Valuing and developing management skills and competencies and having managers who

lead by example • Developing leadership skills and competencies at all levels • Recognising and supporting the role of carers in the delivery of healthcare • Creating a culture of organisational learning • Valuing on-the-job learning and recognising the workplace as major source of learning • Building on the partnership model in place with trade unions and professional organisations

4 RECOMMENDATION The Board is invited to note the following recommendations:

• To establish a sub-group of the Partnership Forum to progress the work involved to effectively embed the 2020 Vision values and behaviours within the hospital.

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MONITORING FORM


LDP – Workforce (paragraph 11.2)

Workforce Implications Improve the staff experience and level of staff engagement

Financial Implications Potential OD / Corporate Training Interventions


Workforce Development Session August 2015 Partnership Forum Staff Governance Committee via 2020 Vision Action Plan


Risks associated with not progressing this work could include increased Employee Relation issues, DAW issues and absence levels.


Improve the patient experience. Deliver high quality patient care.

Equality Impact Assessment No issues.

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Minutes of the meeting of the Staff Governance Committee held on Thursday 3 December 2015 at 10.00am in the Boardroom, The State Hospital, Carstairs. Present: Non Executive Director Bill Brackenridge (Chair) Non Executive Director Elizabeth Carmichael Board Chair Terry Currie Employee Director Anne Gillan Non Executive Director Nicholas Johnston In attendance: Chief Executive Jim Crichton HR Director Barbara Anne Nelson General Manager Mark Richards Board Secretary Jean Wade 1 APOLOGIES FOR ABSENCE AND INTRODUCTORY REMARKS Apologies were received from Alan Blackwood. Bill Brackenridge welcomed everyone to the meeting. 2 CONFLICTS OF INTEREST There were no conflicts of interest noted in respect of the business to be discussed. 3 MINUTES OF THE PREVIOUS MEETING HELD ON 3 SEPTEMBER 2015 The Minutes of the previous meeting held on 3 September 2015 were approved by the Board at their meeting on 29 October 2015. 4 ACTION POINTS AND MATTERS ARISING FROM THE PREVIOUS MEETING Barbara Anne Nelson provided an update on the Action Points from the last meeting which she confirmed were progressing or complete. The following update was also received. a) Internal Audit Report – HR Recruitment Processes Members noted the report which provided an update on the current position in respect of implementation of Internal Audit Recommendations with regard to recruitment processes at the Hospital. The Committee had requested that timescales were provided for the actions to be taken and these were included in the report. 5 MANDATORY/STATUTORY TRAINING COMPLIANCE Members received a verbal report from Barbara Anne Nelson advising that the Committee would receive a report every six months in respect of Mandatory/Statutory Training Compliance at the Hospital. The report would provide an opportunity for the Committee to have oversight of any risks of non compliance and that Internal Audit were currently conducting an audit of this area. The first report would be provided at the next meeting in March 2016 and thereafter in October 2016.

Action: Barbara Anne Nelson

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6 PROTECTION OF VULNERABLE GROUPS Members received a report from Barbara Anne Nelson which provided a Statement of Assurance in respect of Protection of Vulnerable Groups (PVG), which confirmed that the Hospital had completed the retrospective checking exercise for employees by the due date. Barbara Anne Nelson confirmed that details of 430 Hospital staff had been processed and that they now held the required membership of the PVG Scheme. The considerable amount of work undertaken by Rhona Preston and the high level priority approach taken to achieve the required outcome of compliance was acknowledged. The Committee noted that Partnership working had played a significant part in the success of this work. Members noted the Statement of Assurance in respect of Protection of Vulnerable Groups. 7 RECORDING OF DATA Members received a report from Barbara Anne Nelson in respect of recording of data in relation to Dignity at Work, Conduct, Grievance, Whistleblowing and Protected Disclosure. Barbara Anne Nelson summarised the report which provided the background to previous internal reporting mechanisms and the newly established procedures in place which were more robust. It was noted that the new system of recording of data also included all relevant staff governance information and not just that specifically relating to Dignity at Work. Members discussed the report in relation to backlog information which the new system would address; the higher level checking process of the recording of this data, which would be put in place; the concern in relation to the high number of Dignity at Work cases at the Hospital; and the need for visibility of these high numbers, which should perhaps have regular discussion at Partnership Forum, with a quarterly report to Staff Governance Committee. The Committee acknowledged the importance of being sighted on this issue, the need to follow up timeously and to monitor the progress made over time. It was agreed that the Committee would receive a report on Dignity at Work at the next meeting with a report thereafter on a quarterly basis.


Members noted the assurance given that a robust recording system has been introduced within the Human Resources Directorate to record the data on Dignity at Work; Conduct; Grievance: Whistleblowing; and Protected Disclosure. 8 WORKFORCE REVIEW Members received a report from Jim Crichton in respect of progress of the Workforce Review. It was noted that a Joint Workforce Planning event had taken place on Friday 28 August 2015 which identified four key Workstreams, viz Sustainable Workforce: Capable Workforce: Quality Improvement Skills: and Effective Leadership. Substantial pieces of work were now underway to progress the wide ranging areas identified and the leads for each workstream would provide an update, based on the six step methodology on the progression of these areas. The Board would receive an interim Workforce Report at their meeting on 10 December 2015 and the Committee would receive a further update at their meeting in March 2016. Thereafter, the final report would be provided to the Board at their meeting on 28 April 2016.

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Members discussed a number of issues in relation to staff comments at Leadership Walkrounds on the different ways of working within the Hubs; the need for more cohesive leadership arrangements and consistency of core processes within the Hubs which were a priority; the impact these issues may have on attendance management; the importance of having the leadership posts confirmed and re-aligned by March 2016 and to have the training in place to support those involved; the ageing workforce in the Hospital; and the issues, in the short term, of the significant number of nursing staff, with Mental Health Officer Status, who were due to retire at 55 years of age. Anne Gillan stated that Staff Side welcomed the opportunity to be involved in the workforce discussions at the outset of the review and that the transparency of data shared had been positively received on a multi-union basis. For the purposes of good communication, she and Jim Crichton had visited all Hubs and the Skye Centre last week to inform staff of the work underway and the feedback received had been useful to the overall process. Members noted the progress on the Workforce Review. 9a) ATTENDANCE MANAGEMENT REPORT Members received a report from Barbara Anne Nelson which provided an update on Attendance Management. It was noted that from SWISS, the sickness absence figure for the period 1 September 2015 to 30 September 2015 was 9.75% with the long/short term split being 5.84% and 3.91% respectively. The total hours lost for this period was 9,733.66 which equated to 60 wte staff. The current rolling 12 month sickness absence figure was 7.48% for the period 1 October 2014 to 30 September 2015. The total hours lost for this period was 8,494.60 which equated to 45 wte staff. From SSTS, the sickness absence figure for the same 12 month period was 7.90% with the long/short term split being 6.06% and 1.85% respectively. Industrial injuries represented 0.40% of available hours (4,773.38 hours) from 1 October 2014 to 30 September 2015. Members discussed a number of issues of the report in relation to the data presented which the Committee agreed confirmed the unacceptable high levels of sickness absence; the work underway across all areas in the Hospital, for SMT to receive exception reports if sickness absence levels exceeded 7%; and that there was no correlation between high levels of sickness absence recorded in Arran and Mull and Dignity at Work issues. Jim Crichton acknowledged the Committee’s responsibility to keep track of the exception reporting exercise. He confirmed that he would report progress to the Committee at the next meeting and if required, as added value, would arrange for Line Managers involved to attend the Committee to discuss the situation in their area.

Action: Jim Crichton Members noted the content of the Attendance Management Report. 9b) AUGUST 2015 ATTENDANCE FIGURES – FURTHER ANALYSIS Barbara Anne Nelson tabled a report which, following a request at the meeting of the Board on 29 October 2015, provided further analysis of sickness absence figures. It was noted that the appendices to the report provided high level information for the period 1 August 2015 to 31 August 2015 in respect of Absence Reasons by Department; Stress Related Absences (Analysis); Long and Short Term Sickness Absence Reasons; and Capability Stages by Department.

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Members discussed a number of issues of the report in relation to hot spot areas of the data provided; their concern that the Attendance Management Policy was not being applied consistently across the Hospital; the positive ongoing discussions with Staff Side to address the issues of the Policy which should be fit for purpose; the importance of Line Management responsibility and the training required; the improvements expected once HR staffing was at full capacity and the arrival of Head of HR at the beginning of January; the work that was continuing to address the issues of the Internal Audit Review of Sickness Absence; and that the Workforce Planning Exercise had a role to play in the improvements required to the high levels of sickness absence. The Committee felt it would be useful to receive an update at the next meeting of Appendix 4 – Capability Stages by Department.


Jim Crichton stated that the report demonstrated the amount of work being done over a broad range of areas to address the high levels of sickness absence. He confirmed the importance of visibility and communication of the work being undertaken. A report would be provided at the next meeting detailing progress of the primary drivers for improving performance.

Action: Barbara Anne Nelson 10 PERSONAL DEVELOPMENT PLAN PROGRESS REPORT Members received a report from Barbara Anne Nelson in respect of Personal Development Planning and Review as at 26 November 2015. A detailed breakdown by department of completions was provided and summarised. It was noted that a total of 461 staff (74.8% of the target) had a review meeting conducted in the past 12 months and had a Personal Development Plan (PDP) in place, a increase of 1.5% since the previous update in September 2015; a further 138 staff (22.4%) had an out-of-date PDP, a decrease of 2.4% from September 2015; and the remaining 17 staff (2.8%) had no PDP in place, an increase of 0.9% from the previous report. Members were pleased to note the progress made, however were concerned to note that quarter of the workforce had an out of date PDP. The Committee felt it would be helpful to receive percentages of the hotspot areas where staff had an out of date PDP and this would be provided at the next meeting.


Other issues discussed related to the quality of the reviews conducted and the importance of having a good structure in place at the meetings; the improvements expected with the introduction of the Nurse Revalidation process; the possibility of sharing good quality reviews as an exemplar; and the differences across the site between areas with a good rate of completions with those areas that did not. Barbara Anne Nelson confirmed that she would pursue this issue with the Learning and Professional Development Manager and advise at the next meeting.

Action: Barbara Anne Nelson Members noted the report on Personal Development Planning and Review and recorded their thanks to those staff who had completed a review so far this year. 11 STAFF SURVEY UPDATE Members received a verbal report from Barbara Anne Nelson who confirmed that the results of this year’s Staff Survey would be made available to all NHSS Boards later in the month. Terry Currie advised that NHSS Board Chairs had been informed that the national return was 38%. The Hospital had recorded a return of 34% and was a drop on last year’s level of participation. Members would be informed of the outcome once received.


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12 HEALTH, SAFETY AND WELFARE COMMITTEE Members received and noted the approved Minutes of the Meeting of the Health, Safety and Welfare Committee which took place on 13 August 2015. Members discussed a number of issues in relation of the approval of the Legionella Policy, the status of which Mark Richards would confirm at the next meeting.

Action: Mark Richards In respect of the Manual Handling Advisor post, Jim Crichton confirmed the current position of the post and the interim arrangements in place in terms of support from external sources when required and the availability of on-line training for staff. Any outstanding issues would be addressed from April 2016 onwards. 13 PARTNERSHIP FORUM MINUTES Members received and noted the approved Minutes of the meeting of the Partnership Forum which had taken place on 18 August 2015, 15 September 2015 and 20 October 2015. Terry Currie raised the issue of the re-tendering arrangements for the Occupational Health Service at the Hospital. Barbara Anne Nelson advised that a different focus to the tender specification was to be considered and that the current providers were aware of this. A meeting with SALUS Occupational Health would take place early in the New Year and Members would be kept informed of progress.

Action: Barbara Anne Nelson 14 ANY OTHER BUSINESS There was no other business. 15 DATE AND TIME OF NEXT MEETING The next meeting would take place on Thursday 3 March 2016 at 9.15am in the boardroom, The State Hospital, Carstairs.

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Date of Meeting: 25 February 2016 Agenda Reference: Item No: 13 Sponsoring Director: Finance and Performance Management Director Author(s): Senior Project Manager Title of Report: LDP Performance Report Q3 2015/2016 1 SITUATION This report presents a high level summary of organisational performance for the period from October 2015 until December 2015 and is based on the Local Delivery Plan (LDP) and its associated targets and measures. An exception report may be found in Appendix 1 where a “Red / Amber / Green” system is employed to identify performance that is respectively: below target; systems are being improved, performance is within target but diminishing, or performance is unacceptable but significantly improved; and performance exceeding targets. 2 BACKGROUND Members receive quarterly updates on Key Performance Indicator (KPI) performance as well as an Annual Overview of performance and a Year-on-Year comparison each June. Members asked that expected year-end performance of targets be included in the report. These have been included where they have been provided by the KPI Lead. 3 ASSESSMENT We have maintained good levels of performance in many areas but performance in the following areas merit comment: KPI 3 Patients will be engaged in off-hub activity centres Patient attendance has dropped again from in 83% Q2 to 81.4% in Q3. Attendance at off-hub activities does tend to drop off in Q3 each year as more activities and social events take place in the hubs in the run-up to Christmas. KPI 6 Patients will have a healthier BMI The figure has improved from 13% in Q2 to 15% in Q3. Overweight levels have decreased by 8% in 12 months but obesity levels remained static. Dietetics staff are analysing the data further to determine if the improvements are within the patient population included in the previous figures or due to new admissions being included in the data. KPI 7 Sickness absence This has gone down from 9.9% in August to 8.47% in November but remains above target. It is recognised that performance in this area is not acceptable and joint work is being undertaken in partnership to address a variety of actions which should support improvement in this area. These include: promotion of a healthy working environment; supporting staff health and wellbeing;

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developing the skills and competencies of managers including those required to manage attendance effectively; ensuring that the attendance management policy is effective; active surveillance of performance to ensure continuous improvement. KPI 8 Reduction in CO2 emissions for fossil fuels and KPI 9 Reduction in energy consumption Energy and Carbon are no longer HEAT targets and national figures are not being published. A new national system is being implemented and is expected to be up and running from 1st April 2016. The new system is being rolled out and training is scheduled for early March 2016. Once Facilities staff have a better understanding of the new system and how the data are presented, more meaningful reports will be provided on the Hospital’s overall performance on carbon reduction and energy consumption. New targets have been set by the Hospital as part of this year’s Property and Asset Management Strategy (PAMS) 2015-2020. KPI 10 Staff have an approved PDP Performance remains below target at 73% in Q3. Managers have been asked to outline their plans for improving performance within their areas with support from Learning and Development colleagues as appropriate. It has also been agreed that an SBAR process, similar to that used to performance manage attendance, will be introduced for PDPs. This will be set at a figure of less than 75% completion. KPI 15 Patients have their clinical risk assessment reviewed annually Performance remains below the 100% target at 92%. This is a sign off timing issue. Every patient has their risk assessment and management plan reviewed. KPI 17 KPI Attendance by all clinical staff at case reviews Psychology service attendance has been highlighted in red as performance has diminished since the last quarter. Clinical psychologists attend 80% of all patient reviews – this is harder to achieve given that the Clinical Psychologist’s (CP) leave may not be the same as the Responsible Medical Officer’s (RMO) leave and training and other commitments may mean the CP and RMO are not always on site. For example a full time member of staff (RMO/ CP) will have 30 days leave, 10 days training a year and a normal sickness absence rate of 5%. This means that they will be at work 43 weeks a year. If they both have to attend 36 case reviews and their holidays and training commitments are different then Clinical Psychology attendance will be reduced as Case Reviews are scheduled around the RMO’s availability. Any long term absence in the service (sickness or maternity leave) significantly impacts on case review attendance. Nevertheless the target of 80% should still be one to aim for. 100% attendance at patient review by a relevant member of the psychology team should be achievable in the future. While Occupational Therapy attendance remains well below their 80% target performance has improved from 49% in Q2 to 58% in Q3. Gaps in KPIs No data has been reported for KPI5 Patients’ Exercise since August 2013. KPI 14 Meaningful Activity has never been formalised or reported on. KPI 16 Community Meetings has not been replaced by an alternative patient involvement measure since the meetings ceased.

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4 RECOMMENDATION The Board (Committee) is invited to note the contents of this report and endorse the following recommendations:

• The Key Performance Indicators for Physical Exercise, Meaningful Activity and Patient Involvement be reviewed and revised as necessary by their identified Leads with support from the Senior Project Manager.

• The agreed Key Performance Indicators can then be incorporated into the planned Data Warehousing project so that robust systems for collation and reporting of data can be established.

MONITORING FORM


Monitoring of Key Performance Indicator Performance in the TSH Local Delivery Plan (2015-2018).

Workforce Implications No workforce implications-for information only.

Financial Implications No financial implications-for information only.


Leads for KPIs contribute to report.


There continue to be gaps in KPIs reporting, in particular around physical exercise, patient activity and patient involvement (since community meetings ended). However, activity data is collected and managed within services areas and reported to other groups and committees. Patient involvement data is also reported to other groups. There is a need to clarify KPI reporting in these areas.


The gaps in KPI data which make it difficult to assess.

Equality Impact Assessment Implications to be identified.

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APPENDIX 1

Item Code Principles Performance Indicator Target RAG Actual Comment LEAD 1 H 8 Patients have their care and treatment

plans reviewed at 6 monthly intervals 100% A 97% Rolling figure to Dec 2015. Up from 92% in Sept 2015. 3 treatment plans are out of date. (See Note

1: recent admissions) Expected year end – will remain high, aiming for 100%. LT

2 H 8 Patients will be engaged in psychological treatment

90% G 90% Figures for Dec 2015. Down from 97% in Sept 2015. 113 engaged in therapy, 59 engaged in more than one therapy. Of the 13 patients not engaged in treatment – all completed treatment between August and November. Expected year end – continue to meet target.

MS

3 H 8 Patients will be engaged in off-hub activity centres

90% R! 81.4% Figures for Oct-Dec 2015. Q2 figure was 83%. Excludes shop / health centre information (brief visits). See note 3. Expected year end – improvement on Q3 figure.

MR

4 H 8 Patients will be offered an annual physical health review

90% G 100% Figures for Oct-Nov 2015. 27 attended Annual Health Reviews, 15 admission physicals completed, 5 declined and 3 rescheduled. Expected year end – continue to exceed target.

LT

5 H 8 Patients will undertake 90 minutes of exercise each week (Annual Audit)

60% - - The last annual review of Physical Health Activity In August 2013 reported 66%. Audit planned for March 2016. See note 3. Expected year end – target met.

MR

6 H 8 Patients will have a healthier BMI 25% R! 15% Figure from Dec 2015, June 14 figure was 13%. 31.7% of patients are overweight and 53.3% are obese. Next audit due June 16. Expected year end – will not meet target, Consultation Exercise recently considered by Board.

LT

7 E 5 Sickness absence (National HEAT standard is 4%)

** 5% R! 8.47% Rolling figure for November 2015 (awaiting Dec figures). See Note 2. Was 9.9% in August 2015. Expected year end – will not meet target

BN

8 E 5 Reduction in CO2 emissions for fossil fuels

-14.13% - - No longer a HEAT target. In transition to new system. DI

9 E 5 Reduction in energy consumption -3.4% - - No longer a HEAT target. In transition to new system.

DI

10 E 5 Staff have an approved PDR *100% R! 73% Rolling figure for Dec 2015. Down from 74.8% in Sept 2015. Expected year end – to improve on current performance – 75%

BN

11 A 1, 3 Patients transferred/discharged using CPA

100% G 100% Figures for Oct-Dec 2015. 9 patients discharged/transferred. Expected year end – continue to meet target.

PD’M

12 A 1, 3 Patients requiring primary care services will have access within 48 hours

*100% G 100% Figures for Oct-Dec 2015. 728 interventions in Q1 (662 requests in Q4). Expected year end – continue to meet target.

LT

13 A 1, 3 Patients will commence psychological therapies <18 weeks from referral date

**100% G 100% Figures for Dec 2015. 10 patients have waited longer than eighteen weeks for engagement in a therapy however all 10 are involved in other therapies and therefore were/will be delayed in entering specific treatments due to time overlaps (thus individual availability issue, not therapy availability issue). Expected year end – continue to meet target.

MS

14 A 1, 3 Patients will engage in meaningful activity on a daily basis

100% - - See Note 3. MR

15 T 2, 6, 7, 9 Patients have their clinical risk assessment reviewed annually.

100% R! 92% Figures for Dec 2015, 93% in Sept. 9 out of date (3 due to section change). Expected year end – in line with previous year

LT

16 T 2, 6, 7, 9 Hubs have a monthly community meeting.

- - - To be revised. MR

17 Refer to next table. All Clinical Leads

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Item Code Principles Performance Indicator Profession (Lead) Target RAG Overall attendance Oct-Dec 2015 Overall attendance Jul-Sep 2015

17 T 2, 6, 7, 9 Attendance by all clinical staff at case reviews RMO (LT) 90% G 96% 89.8%

Medical (LT) 100% A 98% 97.9%

Key Worker/Assoc Worker (MR) 80% A 76% 67.3%

Nursing (MR) 100% A 98% 97.9%

OT(MR) 80% A 58% 49%

Pharmacy (LT) 60% G 82% 69.4%

Clinical Psychologist (MS) 80% R! 64% 69.4%

Psychology (MS) 100% R! 92% 100%

Security(DI) 60% G 62% 77.6%

Social Work (PDiM) 80% G 82% 85.7%

Skye Activity Centre (MR) tbc - 0% 13%

Dietetics (MR) tbc - 3.8% 0%

* denotes national target; ** denotes HEAT target

Note 1 – recently admitted patients are not included in this calculation. Note 2 - We await further information on how the errors identified in the statistics reported nationally are to be addressed. Note 3 – Annual audit planned for March 2016. There is currently no single, reliable source of data, which could be addressed through the introduction of an electronic activity timetabling system.

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 25 February 2016 Agenda Reference: Item No: 14 Sponsoring Director: Finance and Performance Management Director Author(s): Finance and Performance Management Director Title of Report: Local Delivery Plan 2016-21 1 SITUATION The Local Delivery Plan (“LDP”) is a high level strategic plan covering a 5-year period. The State Hospital has had an LDP in place now since 2006, although the format and information therein has changed in that time. 2 BACKGROUND The most recent major update in LDP structure was in 2015, when the current format was established for a 3-year plan. This plan has now been updated for submission in 2016. The LDP includes a summary of the financial plan for the 5 years to 2020/21 – the full detail of which is the subject of a separate submission to the Scottish Government. For each year, the State Hospital is required to set a balanced budget, as set out in the LDP. 3 ASSESSMENT The LDP is to be submitted to the Scottish Government in draft by 4 March 2016, with final submission for sign-off by 31 May 2016. Unlike in previous years, this allows for the Board is required to sign-off as draft LDP at this meeting, and at the next Board meeting in April sign-off the final LDP. The Board is asked to approve the draft LDP for submission to SGHD and to highlight any comments or revisions to be noted for the next meeting on 28 April. 4 RECOMMENDATION The Board is asked to approve the approach and draft LDP, and to offer comments and revisions as noted above.

MONITORING FORM


LDP document itself for submission for SG approval – supports all areas noted.

Workforce Implications Addressed in Section 11.2 of the draft LDP.

Financial Implications No direct financial implications from the LDP document and submission – the LDP is however supported by the 2015/16 budget from which key aspects are noted in sections 7.3 and 11.3.

Route To SMT Which groups were involved in contributing to the paper and recommendations.

Senior Management Team Members; Clinical and Risk Governance representatives; Staff side representatives; Finance representatives; Procurement representatives; eHealth representatives; Involvment and Equality representatives; Social Work representatives



Assessment of Impact On Patient Experience

None identified.

Equality Impact Assessment No identified implications.

LOCAL DELIVERY PLAN 2016-2021

Reference Number LDP Issue: 16/17 draft#2 Lead Author Finance and Performance Management Director Contributing Authors Board

Senior Management Team Members Clinical and Risk Governance representatives Staff side representatives Finance representatives Procurement representatives eHealth representatives Involvement and Equality representatives Social Work representatives

Targeted audience For Scottish Government and Board approval Approval Group Board Effective Date May 2016 Review Date Next review for 2017/18 Responsible Officer (SMT) Finance and Performance Management Director

The State Hospital

Contents Page 1 Introduction .................................................................................................................. 1 2 About the Hospital ........................................................................................................ 2 3 About the Patients ........................................................................................................ 2 4 About the Clinical Services Provided............................................................................ 3 5 Purpose of the Local Delivery Plan .............................................................................. 4 6 Strategic Aims .............................................................................................................. 5 7 National and Local Drivers ........................................................................................... 6 7.1 Quality ......................................................................................................................... 6 7.2 Clinical Model .............................................................................................................. 8 7.3 Available Resources .................................................................................................. 10 7.4 Efficiency and Productivity ......................................................................................... 11 8 Person-centred .......................................................................................................... 13 8.1 Care and Treatment Pathways ................................................................................... 13 8.2 Patient Experience ..................................................................................................... 14 8.3 Access to Hospital Services ....................................................................................... 15 9 Safe ........................................................................................................................... 18 9.1 Adverse Impact of Patient Behaviour ......................................................................... 19 9.2 Security ...................................................................................................................... 20 9.3 Patient Safety ............................................................................................................ 20 9.4 Child and Adult Protection .......................................................................................... 21 9.5 Healthcare Associated Infection (HAI) ........................................................................ 21 9.6 Clinical Governance ................................................................................................... 21 9.7 Achieving Results through Teams .............................................................................. 22 10 Effective – Health Improvement ................................................................................. 23 10.1 Mental Health ............................................................................................................. 23 10.2 Physical Health .......................................................................................................... 24 10.3 Educational Attainment .............................................................................................. 25 11 Effective – Governance .............................................................................................. 26 11.1 Governance and Management Arrangements ............................................................ 26 11.2 Workforce .................................................................................................................. 26 11.3 Finance ...................................................................................................................... 27 11.4 Property and Assets ................................................................................................... 29 11.5 eHealth and Information Governance ......................................................................... 29 11.6 Procurement .............................................................................................................. 30 11.7 Sustainability .............................................................................................................. 31 11.8 Innovation .................................................................................................................. 31 11.9 Equality, Diversity and Rights..................................................................................... 31 Appendix 1 Quality and Performance Measurement Framework ......................................................... 33 Appendix 2 Summary Corporate Risk Register – updated register to be included ............................... 37 Appendix 3 Glossary of Terms ............................................................................................................ 40

1 Introduction The State Hospitals Board for Scotland (the Hospital) provides assessment, treatment and care in conditions of high security for male patients with mental disorder who, because of their dangerous, violent or criminal propensities, cannot be cared for in any other setting. It is a national service for Scotland and Northern Ireland. The service has established a reputation for providing world class forensic mental health care. Visitors to the service both from home and abroad, have been hugely positive about the patient centred approach and focus on recovery. In conjunction with improvements in care, the opening of the new Hospital in September 2011 provided an unprecedented opportunity to provide high quality care within a modern purpose built facility. Working with partners in our Forensic Network, we aim to maintain our reputation for high standards of care, innovative research and education in 2016/17. Addressing health and social inequalities for our patient group is a major challenge. As a no smoking facility and illicit drug and alcohol free area, the twin challenges of smoking and substance misuse are areas of existing success. Our primary challenge is obesity and its related physical health problems. We have undertaken an extensive stakeholder engagement over the last year and will be taking forward recommendations to promote healthier choices for patients over the coming year. Many of our patients have limited educational attainment linked to a range of factors in their lives prior to admission. This can lead to social exclusion and difficulty attaining employment. Patients benefit from access to recreational and educational facilities on site and are supported to develop their skills and educational attainment during their stay. We are committed to maintaining and improving opportunities for our patients to access both physical and educational activities. The service has embraced the ambitions of the Scottish Patient Safety Programme and has been a key contributor to improvements in patient safety both locally and on the national stage. Work undertaken to introduce post-incident debriefing for example, has led to a significant reduction in incidents of violence or aggression. We will be further developing our programme of patient safety work over the next year and investing in our staff’s access to training in improvement methodology. The State Hospitals Board for Scotland is fully committed to the principles, values and objectives articulated in Everyone Matters: 2020 Workforce Vision. We continue to set out our commitment to our staff to implementing this vision and making real improvements to the health of our organisation as a whole, and to the health of the people who work within it. We recognise that it is the people in our organisation who deliver the service and that the support and contribution of our employees will be crucial in delivering the objectives in this plan. We will be working in partnership to put a significant emphasis on maintaining and improving staff health and wellbeing and ensuring that our NHS values and behaviours are clearly visible by everyone who is part of our service. The financial landscape is challenging and realising the continuous improvement that we are ambitious to achieve, will mean working effectively as a team, ensuring that we are deploying our resources as effectively as we can to meet our patients needs and driving out inefficiencies. Our LDP for 16/17 builds on a shared vision with our staff about our key priorities and how we wish to achieve these now and in the future. Jim Crichton Chief Executive The State Hospitals Board for Scotland

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2 About the Hospital The Hospital is a Special Health Board

and is accountable to Scottish Ministers, and the Scottish Government Health and Social Care Directorate (SGHSCD).

As a National Health Service (NHS)

hospital we are open about our activities and plans. Information about who we are, and what we do is available on our website www.tsh.scot.nhs.uk

Approximately 650 whole time equivalent

staff provide secure psychiatric care 24 hours a day, every day of the year.

The Hospital’s purpose is to ensure public

safety by providing care and treatment of the highest standards.

The main aim is to rehabilitate patients,

ensuring safe and appropriate transfer to appropriate services.

The Hospital is located in Lanarkshire in

central Scotland, midway between Glasgow and Edinburgh.

Services are primarily provided for male

mental illness. There is a dedicated service for male patients with an intellectual disability.

Hospital staff work in partnership with

South Lanarkshire Council which provides social work services for patients and their families.

3 About the Patients Patients are admitted to the Hospital

under requirements of the Mental Health (Care & Treatment) (Scotland) Act 2003 or Criminal Procedures.

The Hospital has 140 available beds, in an

environment of high security. 79% of patients have a primary diagnosis

of schizophrenia; 72% have a multiple diagnosis.

The average age of patients is 42 years. The average time spent in the Hospital is

approximately 7 years. However, this ranges from less than one month to over 48 years.

Of the patients ready for transfer, at any

one time, between 5 and 12 were waiting more than 3 months (but less than 12 months) for appropriate local services to implement the transfer.

27 patients were admitted during 2015: 7

from NHS hospitals, 10 from prisons and 10 from the courts.

35 patients were discharged or transferred

during the same period: 26 to NHS hospitals, 3 to prison, 4 to the courts, 1 to a detention centre and 1 to the community.

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http://www.tsh.scot.nhs.uk/

4 About the Clinical Services Provided Diagnosis is through assessment and formulation of patient risks and needs (psychological, physical, functional, social and spiritual). Each member of the multidisciplinary clinical team contributes. The aim is to address identified treatment needs to support recovery from mental disorder and reduce the risk of future offending. When appropriate, the aim will be for the patient to move on, whether that is return to prison, transfer to a lower security hospital, or, in rare cases, discharge into the community. This takes on board best practice recovery models and approaches. Risk assessment and management is integral. Services for patients with an intellectual disability tend to be more intensive, at a slower pace, and have a greater need for consistency, communication and engagement. A significant number of patients have one or more risk factors for cognitive impairment, secondary to longstanding severe schizophrenic illness, substance misuse (including alcohol) and acquired brain injury. Such impairment may impact on patients’ understanding of, and compliance with, treatment. Assessments are carried out on admission and include specialist assessments for areas of specific identified difficulties. This should lead to services being tailored to meet individual need. The need for processes to be in place to support early detection of dementia is addressed through cognitive screening as part of the psychology assessment undertaken on admission; and by clinical teams being alert to patients who present a reasonably high index of suspicion (certain patient groups are more susceptible). When required, a specialist neuro-psychology assessment is conducted. Treatments and activities are provided within high secure conditions, and are tailored to meet the requirements of individual patient risk assessment and management plans.

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5 Purpose of the Local Delivery Plan The Local Delivery Plan (LDP) sets out a delivery agreement between the Scottish Government Health and Social Care Directorate (SGHSCD) and the Board, based on Ministerial targets. The national approach supports the Scottish Government National Outcomes Framework (Scotland Performs). There is annual review and refinement of the Board’s LDP. The LDP outlines the objectives for the Hospital and aims to provide clarity of strategic direction and financial planning, ensuring that there is an integrated and comprehensive planning process. As the overarching strategic plan, the LDP provides the focus for personal objectives at all levels, and for other strategies and plans. The Board acknowledges the importance of engaging with stakeholders. A consultation process takes place each year to update the plan and to refresh the performance targets and measures. For the 2016/21, LDP, it is approved by the Board in April and SGHSCD in May 2016. The LDP has undergone a substantive review in recent years – the aim being to focus less on describing the activities of the Hospital and more on capturing the desired changes in outcomes. A three tier quality and performance framework was developed: • Long term outcomes (population level indicators, changes observed over a number of years).

• Intermediate outcomes (changes in the determinants of long term outcomes, changes

observed during the course of a year).

• Short term outcomes (service delivery outcomes, performance targets and improvement measures required at team / departmental level to measure progress towards longer term outcomes).

Monitoring systems are in place to review progress ultimately leading to achievement of quality improvements, standards, targets and outcomes as set out in Appendix 1. Performance targets have been aligned with the three quality ambitions in the national Quality Strategy. Ultimately the Board’s performance is reviewed through an Annual Review with Health Ministers and senior SGHSCD officials. Actions arising from the review are included in LDP monitoring.

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http://www.scotland.gov.uk/About/scotPerforms

http://www.scotland.gov.uk/About/scotPerforms

6 Strategic Aims The strategic aims of the Hospital are:

Health Improvement

Improving healthy life expectancy and

encouraging healthy lifestyles

Access to Services

Patients have quicker,

easier and greater use of services

Efficiency and Governance

Improvements

Continually improving efficiency and effectiveness

Treatment Appropriate to Individuals

Patients receive high quality services

that meet their risks and needs and which maintain public, staff and patient

safety

These strategic aims will be achieved by: • Provision of the highest quality person centred, safe and effective services.

• Facilities and services designed to provide an appropriate environment for the delivery of

quality patient care and treatment in a secure setting.

• Competent and motivated staff supported by a developmental organisational culture and positive human resource policies and practices.

• Respect for the human rights of the individual, achieved through a culture based on personal dignity and the active involvement of users and their families.

Underpinned by: • A future direction and strategy which is clear and implemented through effective decision

making, aligned planning processes and clarity of individual roles.

• An organisation that respects the views of staff and patients, learns from past experience, and is transparent in its actions.

• Effective working arrangements with other health, social and legal systems to achieve improved benefit for patients.

• Effective corporate, staff and clinical governance arrangements designed to achieve performance requirements and effective use of resources.

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7 National and Local Drivers The Local Delivery Plan is set in the following context. The twin national drivers of fiscal restraint and the drive for quality are over-arching priorities that must flow through all strategies and plans. The Hospital’s Clinical Model sets the local agenda for delivery of services to patients and must be embedded in all supporting strategies, policies and procedures. 7.1 Quality The Scottish Government is committed to its 2020 Vision for Health and Social Care, for which a Route Map has been developed to provide key actions in support of turning this Vision into a reality – targeting 12 Priority Areas for improvement and 25 Key Deliverables. Deliverables 6-18 are not applicable to The State Hospital, nor are the following Priority Areas – Primary Care, Unscheduled and Emergency Care, Integrated Care, Care for Multiple & Chronic Illnesses, Early Years, and Health Inequalities. The Route Map as it applies to the State Hospital is shown below:

ROUTE MAP TO THE 2020 VISION FOR HEALTH AND SOCIAL CARE

Triple Aim Quality Ambitions

12 Priority Areas for Improvement 25 Key Deliverables

Quality of Care

Person-centred

Person-centred care

1 Person Centred Health & Care Collaborative Implemented

2 Information and support to enable people at home and during times of transition

Safe Safe Care

3 Further increase in safety in Scottish hospitals

4 New broader measure of safety developed (SPSI)

5

Maternity, mental health and primary care components of the Scottish Patient Safety Programme implemented with measurable improvements

Health of the Population

Effective

Prevention 19 Early detection of cancer

20 New restrictions on tobacco advertising

Value & Sustainability

Workforce 21 2020 Vision for NHSScotland

workforce

22 Detailed action plan agreed to deliver 2020 Workforce Vision

Innovation

23 A new fund to provide pump-priming for innovative approaches to healthcare

24 A new procurement portal will be established to encourage working with SMEs and third sector

Efficiency & Productivity 25 Recommendations to increase

shared services The key deliverables as noted are addressed by The State Hospital within this Local Delivery Plan, and each deliverable is allocated an executive lead contact – who has the responsibility for the monitoring of progress, and for the development of these deliverables through 2016/17 as the LDP continues to become integrated with the 2020 Vision.

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The following table maps the key deliverables for The State Hospital to the lead contacts and relevant section of the LDP.

25 Key Deliverables TSH Executive Lead Contact LDP mapping

1 Person Centred Health & Care Collaborative Implemented Nursing Director Section 8

2 Information and support to enable people at home and during times of transition Nursing Director Section 8

3 Further increase in safety in Scottish hospitals Nursing Director Section 9

4 New broader measure of safety developed (SPSI) Nursing Director Section 9

5

Maternity, mental health and primary care components of the Scottish Patient Safety Programme implemented with measurable improvements

Nursing Director Section 9

19 Early detection of cancer Medical Director Section 10 20 New restrictions on tobacco advertising Medical Director Section 10 21 2020 Vision for NHSScotland workforce HR Director Section 11

22 Detailed action plan agreed to deliver 2020 Workforce Vision HR Director Section 11

23 A new fund to provide pump-priming for innovative approaches to healthcare General Manager Section 11

24 A new procurement portal will be established to encourage working with SMEs and third sector

Finance and Performance Management

Director

Section 11

25 Recommendations to increase shared services

Finance and Performance Management

Director

Section 11

The 2020 Vision develops further the NHS Scotland Quality Strategy which was launched in May 2010. The ultimate aim is world-leading person-centred, safe and effective healthcare in Scotland. The Quality Strategy sets out ambitions for NHSScotland, focussing around three of the six quality dimensions: person-centred, safe and effective – now the Quality Ambitions within the 2020 Vision. All strategies and plans should be set in this context:

1. “person-centred” – mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision making;

o Ongoing focus on – carers in case reviews; volunteering services; National Person Centred Care programme.

2. “safe” – there will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times;

o Ongoing focus on – patient safety in Mental Health Programme; quality improvement methodology; nutrition and weight management; incident reviews; leadership walkrounds.

3. “effective” – the most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated

o Ongoing focus on – Skye Centre development plan; patient day review programme; operational review – the way forward; performance management; leadership and team development; review of efficient use or resources.

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http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality

These areas of focus are addressed in sections 8-11.

As part of the Quality Strategy, the Hospital identified ten quality commitments which are referred to through this document. A Healthcare Quality Standard was published in July 2011, replacing the Clinical Governance and Risk Management Standard. The HEAT performance management framework is embedded as an integral part of the drive to improve quality. The quality measurement framework for Boards is laid out in the diagram below.

7.2 Clinical Model The Clinical Model was signed off in May 2009 having been subject to extensive consultation. It sets out the principles and aspirations for how modern forensic mental health services should be delivered in the new Hospital. The vision is to provide high secure care for those who require it by working more closely with partners in health and social care to achieve the best outcomes for each patient that will be realised through a combination of recovery, rehabilitation, risk assessment, treatment and management. All interventions will be based on the best evidence and practice in the field of forensic healthcare and will take account of the rights of individuals to lead as independent a life as possible within the context of public safety and the safety and security needs of patients. The central aim of the Clinical Model – “Patients will be able to access high quality treatment that is delivered promptly and effectively, that supports recovery from mental illness, maximises social and emotional functioning and reduces the risk of serious harm to self or others”

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http://adsp02/NewHospital/ClinicalModel/Pages/default.aspx

This Clinical Model emphasises the 3 NHSScotland Quality Ambitions – “Effective, Person-centred and Safe” (see 7.1) – and is underpinned by the undernoted 9 Clinical Model principles / objectives. Each of these in turn has a number of specific actions and commitments – a balanced mix of high-level and low-level actions identified to ensure the State Hospital moves closer to the overall central aim. The nine Clinical Model principles are each specifically addressed through sections 8-11 of this LDP – as detailed below – with regard to actions completed, underway and planned for 2016/17. Clinical Model Principle LDP Section 1 Integration. 8.1 – Care and Treatment Pathways 2 Patient focussed care. 8.2 – Patient Experience 3 Individualised care pathways 8.3 – Access to Hospital Services 4 Positive therapeutic milieu 9 – Safe 5 Supporting staff 11.2 – Effective – Governance - Workforce 6 Strengthen multi disciplinary working 9.7 – Achieving Results through Teams 7 Violence risk assessment and management 9.1 – Adverse Impact of Patient Behaviour 8 Comprehensive mental and physical health

care and treatment 10 – Effective – Health Improvement

9 Clinical governance informs and strengthens care

9.6 – Clinical Governance

The Hospital continues to provide a significant opportunity to improve care and ultimately the outcomes of the work that is done. In order to achieve this we will continue to: • Assess, admit, treat, manage and discharge patients using care programme approach and

integrated care pathways. • Tailor care to the needs of patients in terms of range, timing and the least restriction

necessary. • Robustly ensure risk assessment and management plans are responsive to the changing

needs of each patient. • Employ modern technology and solutions that improve security and manage risk. • Provide access to health and wellbeing activities that promotes engagement, recovery and

hope in the future. • Ensure that staff are trained and supported to adopt new ways of working that are based on

need, rather than historical practices. • Deliver clinical leadership by confident well equipped people who develop their teams and

make use of performance management information. In addition, during 2015, a review of the Clinical Model was carried out to assist the patient activity / patient day project, to address the issue of progression raised by the Patient Partnership Group and to assist with the overall Hospital workforce planning. This focussed on: • Evaluating the existing ward configuration against the ambitions of the Clinical Model. • Identifying whether there is a need for service change, or an opportunity for improvement or

major redesign. • Identifying objectives for future service delivery. • Generating and developing options. • Agreeing a way forward.

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Four high level actions were proposed: • Inactivity and activity are the core work of the Patients’ Day Group and the issues identified

will be incorporated into the project. It was agreed that a desktop exercise to ‘try out’ patient movement options should be arranged.

• Meeting the differing therapeutic needs of patients within the current Hub configuration. It

was agreed a clear operational model which defines the hub function and addresses the needs of the different groups should be produced.

• Addressing variation and ensuring consistency of practice across hubs and wards. It was

agreed that there was a need for clarification of policies and improved confidence in the application of policies.

• Addressing patients’ perception of progress. It was agreed that a paper on the issues

reported by patients should be discussed by the Hospital’s Clinical Forum in December 2015.

The Clinical Forum also discussed potential clinical grouping of patients. A desktop exercise was carried out to ascertain the numbers within the following groups: admissions, pre sentencing, learning disability, the elderly, long term care, rehabilitation, pre transfer, intensive care (HDU), personality disorder, physical ill health and English as a second language. It was established that further exploration of a high dependency unit model and a pre-transfer model was worthwhile, and this in ongoing into 2016/17. 7.3 Available Resources Scottish public expenditure is expected to fall in real terms, as in previous years, in the period to 2016/17. The revenue position for the NHS has been protected – however that vital protection needs to be seen in the context of the global pressures on health spending. The Scottish Spending Review and indicative budget for 2016/17 sets out the national scene. Special Health Boards’ revenue funding will increase overall by 1% in 2016/17. Notwithstanding the increase in NHS funding, the NHS will still face considerable budget pressures, including the forecast 1% increase in payroll for all salaries, incremental drift, and the increase in Employers’ National Insurance in 2016/17 due to pension changes. These pressures mean that the NHS will need to deliver maximum value through a focus on improving the quality of care by prioritising changes which also deliver greater efficiencies. These savings will continue to be retained by NHS Boards for reinvestment in frontline services. Scottish Government proposes 5% savings and this is evident in the tables that follow. The Hospital’s revenue expenditure grew from £33.2m in 2012/13 to a planned £34.3m for 2016/17. In 2010/11, the Hospital began to hand back net savings from the Hospital redevelopment. The final hand back of £250k was to be made in 2015/16, however due to financial pressures Scottish Government allowed an extra year and the final £100k will be paid back in 16/17, which has been built in to the draft LDP. By then the full £1.804m of redevelopment savings will have been returned to SGHSCD.

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Since the Hospital undertook a major construction programme to replace circa 90% of the site, capital resources (excluding those related to the property strategy) peaked at £3m in 2008/09 and then reduced to £300k which has also been anticipated for 2016/17. There is no anticipated resource for property in the current three-year plan from 2015/16. The next significant capital item in this regard is the planned security refurbishment in 2017/18 – estimated at £5m. The projected level of available resource will continue to present a major challenge for implementation of the Property and Asset Management Strategy, especially around security and IM&T equipment replacement programmes.

7.4 Efficiency and Productivity The Hospital is committed to supporting the drive for efficiency and productivity. The Hospital’s savings targets have been met in each of the past few years. Cash savings have been handed back to SGHSCD in line with the Full Business Case for the Hospital Redevelopment (with the final balance of £100k due in 2016/17). In future years, it is very likely that the Hospital will have increasing difficulty generating the same level of cash releasing savings. In order to ensure that service delivery can continue to improve and develop, the focus will need to move to improvements in operational productivity. This will require a new approach to driving and monitoring efficiency and productivity. The NHS Scotland Efficiency and Productivity Framework describes strategies for cost avoidance and reduction which need to be combined with a drive to release resources associated with traditional ways of organising and delivering services. To achieve this staff need to be supported to use good quality data, together with their unique insight into service provision, to identify where productive opportunities lie.

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The Framework has three overarching themes: • Support - supporting our workforce. • Enablers - identifying, sharing and sustaining good practice. • Cost Reductions - reducing variation, waste and harm. The Support theme is linked closely to the Quality Strategy and highlights the importance of staff being appropriately skilled to deliver the necessary change. Open communication will continue through close partnership working, our commitment to staff governance and our contribution to NHSScotland shared services initiatives. The Enablers include: • Benchmarking and the right quality, performance and productivity data. • The effective use of technology in the delivery and redesign of healthcare. Some relevant Cost Reduction work streams, underpinned by the support and enablers, identify where there are further savings and quality improvements to be made: • Evidence based care. • Workforce productivity. • Prescribing, procurement, support / shared services. • Service redesign, innovation and transformation.

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8 Person-centred This section describes patient treatment and care pathways and focuses on timeous and appropriate admission, treatment and transfer of patients. Much of this can only be achieved effectively in conjunction with partner agencies. Systems and processes, from pre-admission through to aftercare, ensure the multi-disciplinary assessment of the health and social care needs of patients, and the risk of harm posed by them to themselves and others. 8.1 Care and Treatment Pathways Clinical Model principle 1: integration Clinical care which includes medical, psychological, social care, education and life skills development are all essential and must be co-ordinated and combined in care planning that tackles the needs and risks of each patient. Integration of all three security domains - physical, procedural and relational - will be fully integrated with clinical care and enhance the opportunities available to patients. In supporting this Clinical Model Principle, during 2015/16 we have: • Continued with daily planning meetings to support co-operative multi-disciplinary working. • Updated and implemented the revised risk assessments on electronic patient records. • Continued to develop the electronic patient record through forms that allow us to monitor

adherence with hospital policy • Completed the Forensic Network Inpatient census. We are also now – for 2016/17: • Reviewing the effectiveness of the operational management arrangements. • Developing automated reports from the electronic patient record to help inform patient care. The Care Programme Approach (CPA) is well embedded as the process of managing individual patient’s care and treatment. Standardised approaches to individual patient documentation are driven through integration of structured risk assessment and management into the care and treatment plan. CPA documentation introduced in March 2012 ensures that patients attend their case reviews and are engaged in understanding the reports that their clinicians write prior to attendance at their case reviews. The Integrated Care Pathways (ICP) system is used to track agreed interventions and is widely used to generate variance analysis reports. Management of patient flow requires, and is based on, effective partnership working with geographical NHS boards and a range of external agencies. The clinical model identifies the need for policies and procedures to be linked to other local or national services, and the potential for being proactive in offering follow up and after care. This is currently taken forward on an individual case by case basis. We have joint high and medium secure referral guidance through the Forensic Network; a weekly Network referral and bed report; and an exceptional circumstances clause that allows the admission of patients requiring medium security to high security in the absence of a medium security bed. These patients are monitored to ensure an early move to medium security. The Forensic Network has established a quality framework with Healthcare Improvement Scotland (HIS) to introduce self-assessment and a peer review process across the forensic estate. The framework is based on the standards already developed by the Network for high, medium and low security. The State Hospital was reviewed in 2013. It was noted that for the majority of the standards the Hospital was at an acceptable stage. An action plan was agreed and is being overseen by the Clinical Governance Committee.

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The actions include: • Liaising with admission referring organisations as part of ongoing review of efficiency of their

new admission process. • Formally agreeing and implementing an employability pathway. • Exploring ways to further demonstrate and promote the link between the engagement in

physical activity and the positive effects on mental health. • Improving its process of formal post incident debrief to ensure consistency across the site. • Continuing to build on work already established for individual and group supervision and

reflective practice to achieve consistency across the site. The Forensic Network is currently reviewing the current Medium and High Secure Care Standards with a view to making them more challenging for all health boards. In addition, we have encouraged research endeavours across the estate; pharmacy audits now take place as a network and close working in education, nutrition and smoking cessation are examples of improvement in quality. These initiatives also serve to support the TSH Quality Commitments: • Commitment 9 “A visible record of treatment and achievement for patients’ personal use that

demonstrates meaningful engagement”. • Commitment 10 “Further develop the quality of the patients’ pathway across the forensic

estate in Scotland through improved collaboration with key forensic stakeholders”. 8.2 Patient Experience Clinical Model principle 2: patient focussed care As outlined in the National Services Framework, we will place patients and their carers at the centre of all service planning and delivery. In addition, the patient-focused approach will ensure the use of our buildings and estate will enhance autonomy and choice and will improve the quality of patients’ lives. In supporting this Clinical Model Principle, during 2015/16 we have:

• Evidenced more robust and meaningful completion of Equality Impact Assessments which

supports the principles of service design based on person-centred values. • Evaluated quality of care via the 2015 Patient Experience Questionnaire report which

indicated that 87% of patients feel the Hospital provides services which meet individual needs. This is an increase of 6% when compared to the feedback provided in 2014.

• The patient experience and visitor survey has evidenced that 86% of visitors feel safe when within the Hospital environment, also a 6% increase when compared to 2014.

• Completed the initial phase of developing a quality improvement approach to support the reporting of all aspects of feedback with an emphasis on demonstrating how the learning has enhanced service delivery.

• Completed the Care Programme Approach Patient (CPA) Input Tool Pilot due to be considered by Clinical Forum regarding more widespread use.

• Commenced a review of Involvement and Equality systems and processes informed by quality improvement methodology, supported by successful completion of the Scottish Improvement Leadership qualification.

• Supported stakeholders to participate meaningfully in the formal Annual Review process. • Undertaken a comprehensive consultation process relating to Supporting Healthy Choices.

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Currently under development for 2016/17: • Review of Involvement and Equality Service roles in line with work streams arising from

current Business Support discussions. • Development of a Hospital wide, aggregated, feedback reporting system, supporting the

organisation to share and learn from positive feedback as well as identify opportunities to enhance existing service provision.

• New hub specific patient information booklet. • Review of visit booking process. • New Volunteering Strategy. • Investing in Volunteers Reaccreditation The Hospital has a robust KPI framework which includes quantitative, qualitative and outcome based measures. The annual patient questionnaire provides structured feedback and measures improvement through retaining some core questions and monitoring of an agreed action plan. Additionally, the annual visitor experience questionnaire ensures the organisation continues to embrace learning opportunities identified from the feedback provided. The “Learning from Feedback Report”, in addition to the Participation Standards Self-Assessment, provide evidence of engagement with patients and their carers. Carers are represented through a number of fora including consultation groups, focus groups and the Carers’ Support Group – central to supporting and facilitating active consultation and engagement. Additionally, the Hospital supports National Carers’ Week every June, in which carers are encouraged to actively participate. 8.3 Access to Hospital Services Clinical Model principle 3: individualised care pathways Each patient will have an individualised care pathway that reflects the care programme approach and begins at the pre admission assessment phase and continues to the point of discharge. In supporting this Clinical Model Principle, during 2015/16 we have: • Actively encouraged patients to engage in the planning and evaluation of their care. Patient

attendance at case reviews has again increased this year, from 78% to 81% for continuing care reviews. 83% of patients participated in transfer / discharge CPA meetings.

• Continued with the focus on weekly reporting on patient activities to clinical teams to support patient engagement.

• Engaged with available arts therapies (drama, music and art therapy). We are also now – for 2016/17: • Evaluating the results of the review of the approach to the “patient’s day”, integrating with

improved patient timetabling to maximise opportunities for patients. A programme of work (with dedicated resources) is now in place, addressing the following key objectives with specified actions as noted: 1 – Review and evaluate the current range of activities on offer –

• Establish stakeholder likes / preferences. o Consultation with patients, staff and key stakeholders took place to establish

stakeholder likes / preferences. Outcomes shared with staff and with patients via the Patient Partnership Group (PPG).

• Identify functional capacity in both Skye Centre and Hubs. o Reports being provided to SMT and actions identified in relation to curriculum

planning and management of staff resources across the Skye Centre. Outcomes of this report formed the basis for the new Activity Planning initiative across the Hospital.

• Enhance visiting experience. o Patient visits extended within Botanics and now provided twice a month supported

by Involvment & Equality, in addition to weekend visiting.

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2 – Hub Interface –

• Review planning processes for patient timetable. o The Patient Activity initiative will provide a platform for the initial work outlined by

the Skye Centre to develop a fully integrated model across all disciplines. • Improve integration with care and treatment plans, and between Skye Centre and Hubs.

o There is ongoing work to develop the integration of clear treatment goals and outcomes for patients accessing the Skye Centre. The development of RIO has proved very positive in allowing consistent sharing of clinical information.

• Identify opportunities for staff development. o The KSF PDP process has enabled the skill mix and development needs of the

staff group to be identified in support of the changing needs and demands of the service delivery.

3 – Review and develop opportunities for Volunteer Support –

• Evaluate opportunities for volunteers. o Volunteers are currently working in several areas across the Skye Centre with

plans for further development. They currently provide regular support for patients in Patient Learning, gardens, the shop and the café area.

• Review / develop opportunities for patient “worker” roles and “support” roles within the Skye Centre.

o A review of the patient “worker” role has been completed, introducing a consistent and standardised process for our patients. Further work is underway to look at the support and resource required to enable more patients to access these opportunities.

• Develop peer support roles. o Initial discussions have taken place to identify appropriate areas in which peer

support roles can be introduced. For example Patient Learning has been identified as an area in which peer support could be provided at both Hub and Skye Centre level.

4 – Explore links with colleges and other educational establishments:

• A total of 10 vocational programmes were successfully delivered during 2015 with a total of 38 vocational qualifications being achieved. The various programmes were delivered across a range of activity centres / services within the Hospital. These included National Qualifications in Laying Slabs & Paving, Horticultural Fence Construction and Use of Hand Tools in Horticulture.

• Identify staff development needs associated with curriculum development and expansion. o The anticipated training for SQA Assessor qualification did not proceed as

anticipated during 2015 however dates have been agreed and confirmed for February 2016. These awards are being delivered in partnership with West Lothian College and aim to equip staff with the knowledge and skills required to support programme delivery and curriculum expansion.

These initiatives also serve to support the TSH Quality Commitments: • Commitment 1 “Expand the range of social and vocational activities available to patients”. • Commitment 2 “Improve access to social, vocational and outdoor activities”. Patients access the Skye Centre as an expected part of the daily menu of activity. Access to therapeutic services is based on needs, using a single integrated system. There is regular review of which patients do not have access to services, to ascertain the reasons, and to ensure that as many patients as possible have time off their ward.

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Other initiatives In addition, Implementation of the revised model for psychological and psycho social therapies means that more care is delivered on an individualised and flexible basis, leading towards the majority of these services being delivered at a hub level. The use of key workers (and associate workers) is critical in supporting the patient to gain the best outcomes. As part of the matched stepped care approach, low intensity ward-based psychological and occupational interventions are applied together with intensive support and engagement for the hard-to-reach patients unable to access off-hub services. Maximising the patients’ day is a significant objective for clinical teams. An electronic therapeutic timetable for each patient is constantly monitored, and formally reviewed as part of case reviews. Flexibility and patient choice remain important criteria which are taken into account. A working group on patient activities is ongoing which is developing new methods of approach to maximising the productivity of each patient’s day. For those patients who are hard-to-reach or challenging, the skills and expertise of occupational therapists are essential to ensuring there is access to meaningful structured routines and therapy that reduces isolation and frustration – and supports reintegration into the wider environment. Policies for prevention and management of violence and aggression, and grounds access are regularly reviewed to maximise opportunities for patients to access services safely and flexibly. The full PMVA policy was introduced in August 2011, and is regularly reviewed and updated to support changes in practice.

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9 Safe

The Hospital is committed to providing expert, high quality treatment and care delivered by multi-professional teams in a safe and secure setting. Detailed strategies, plans and frameworks take account of relevant national standards and guidance; set out the approach to delivery of a quality service; and lay down requirements for continuous review of policy, systems and processes. Clinical Model principle 4: positive therapeutic milieu We will create positive learning and enabling environments that support personal development and skills acquisition, recovery and encourage self management. All clinical staff will use a reflective practitioner model in their day to day working lives. In supporting this Clinical Model Principle, during 2015/16 we have: • Implemented a kitchen-based life skills group. • Focussed on 10 Essential Shared Capabilities as the core ethical competencies for staff. • Successfully continued with themed learning activities across hubs and the Skye Centre. • Supported Mental Health Steering Group projects such as therapeutic milieu, clinical

systems, and mental health outcomes work. • Introduced new psychological interventions to support patients who have difficulties

maintaining and sustaining relationships with others (Mentalisation Based Therapy and Relating Well).

We are also now – for 2016/17: • Piloting the reviewed TUNE IN – emotion management programme • Introducing low intensity trauma interventions – possibly as part of the Road to Recovery

modules • Exploring the feasibility of family interventions for patients with close families A milieu model of care suggests that clinical interventions interact in their effects on the patient through the medium of multiple social interactions. The Hospital has implemented a positive therapeutic milieu model that makes the core components explicit in routine evaluation, performance management and proposed service development. An evaluation framework is in development measuring four separate activities to judge the degree to which the Hospital is matching the principle components of evidence based milieu interventions: • The amount of human contact a patient has. • The number and types of roles a patient fills. • The number of different professionals a patient is exposed to. • The amount of choice a patient experiences. Currently more localised evaluation of the specific changes in the milieu workplan are being carried out – for example qualitative evaluation of the ward talking groups. In addition, a new group (The Relational Approaches to Care Group) was established to address further interventions to improve milieu and address problems as a result of personality disorder.

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9.1 Adverse Impact of Patient Behaviour Clinical Model principle 7: violence risk assessment and management Clearly set out violence risk assessments will be developed throughout the care pathway for all patients. The risk plans will make explicit the individual’s present, past and future risks and include victim safety. Clinical and security safety plans to address each component will be outlined and reviewed regularly. In supporting this Clinical Model Principle, during 2015/16 we have: • Reviewed on an ongoing basis the approach to psychological therapies. • Integrated risk assessment and planning into care and treatment planning, the Care

Programme Approach (CPA) and Multi-Agency Public Protection Arrangements (MAPPA). • Maintained 100% compliance with transfer and discharge CPA. • Introduced the new HCR3 risk assessment tool and have it available on the electronic patient

record We are also now – for 2016/17 – • Working towards developing specific psychological formulations for all our patients that can

be shared and acted on by all members of the clinical team. Violence risk assessment and management standards include: • All clinical teams must adhere to a standard risk assessment and management protocol. • Structured professional judgement tools must be used for violence and sexual violence

assessment. HCR-20 is the tool of choice for risk of violence assessments, and risk sexual violence protocol for risk of sexual violence.

• Risk assessments and management plans must be updated and reviewed at the intermediate and annual review.

• Risk assessments must never be completed in isolation and must be embedded into the patient’s care and treatment plan.

Given the RMA wish to provide accreditation for the forensic network as a whole, it has not been possible to pursue specific RMA accreditation just for the Hospital. We are nevertheless confident that the TSH manner of conducting violence risk assessment and the subsequent development of appropriate risk management plans is based on current evidence and good practice. The management of patients who present with sometimes severe and challenging behaviours which manifest in periods of violence and aggression to themselves or others is normally reflected in: • Some patients requiring increased observation, sometimes with one dedicated nurse, at other

times more than one. • Some patients being cared for away from their peers, in a dedicated area of a ward, usually

with a small team of three or four nurses dedicated to that individual. For patients with serious physical health problems or illnesses, there is a requirement to either care for them with a dedicated team or ward, or transfer to a local general hospital with a dedicated team of two or three nurses escorting the patient 24 hours a day. This places a significant pressure on nursing resources, and if excessive, pressure also on other services. The Hospital tightly monitors this high risk area. There are two basic measures to show the impact of clinical activity: levels of observation and adverse events.

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9.2 Security The Hospital’s secure environment is provided by three domains of Security: • Physical security. • Procedural security. • Relational security. Physical security is provided through high quality physical barriers and sophisticated electronic detection and observation systems. Procedural security is provided through Policies, Procedures and working practice. Relational security is provided by clinical staff working closely with patients to deal with illness and offending behaviour. The Clinical Model sets out how the hospital delivers safe and effective relational security as an integral part of its clinical work. To assist in this the Security Department has Security Liaison Managers working as part of Clinical Teams. The Hospital has its own Security Standards, which are aligned to the national High Secure Care Standards produced by the Forensic Network and adopted as national policy. Compliance with Security Standards is audited by the Forensic Network and an external advisor. At the time of the most recent audit a small percentage of non-compliant areas were identified; these do not present a significant risk to the security or safety of the Hospital. In the latter months of 2015/16 and through 2016/17 a review of perimeter security is being undertaken to establish the longer term requirement for investment to ensure that security remains effective and proportionate. 9.3 Patient Safety The Patient Safety Group continues to evolve, and has continued to contributed to the national Mental Health Patient Safety Strategy with representatives from the hospital on all the national workstream development groups. This has many similar objectives to the Hospital’s local strategy, and reinforces the approach that has been taken thus far. The national Mental Health Programme is accompanied by supporting tools, methodologies and national training programmes. These programmes and methodologies are supporting our efforts to reduce or avoid the harm caused to patients. A successful visit took place in February 2016 from IHI, Scottish Government and the national SPSP MH team who all commended the hospital’s efforts in taking forward projects involving all the workstream areas. Following another year of successful roll-out 2015/16, our priorities for 2016/17 include: • Rolling out (spread) of successful pilot initiatives including post incident debriefs. • Formally evaluate the leadership walkrounds. • Facilitating a further “staff safety climate tool” and an integrated “patient safety climate tool”

ensuring feedback and action planning. • Further attendance and Regional and National Learning Sets. • Commence further relevant small tests of change on safety issues, in particular a workstream

on reducing medication errors. • Integrate patient safety within a wider quality improvement model.

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9.4 Child and Adult Protection The protection of children and adults from harm remains a key priority for The State Hospital, with clearly defined responsibilities for staff from all disciplines. The legislative background is underpinned by local policies and procedures. These primarily include The State Hospital Child Protection and Child Contact Operational Policy and Procedures, and The State Hospital Adult Support and Protection Policy, however other local policies and procedures are also relevant. An integrated approach to Child and Adult Protection at the State Hospital is now embedded into practice, and related work and priorities are overseen and driven by the Child and Adult Protection Forum (CAPF). The meeting frequency was changed from monthly to bi-monthly during 2015. The CAPF acts as a dedicated resource for the Hospital, assessing risk in relation to keeping children safe, prioritising adult protection, and adopting a lead role in terms of policy and practice development. In 2016/17, we will continue to build on this, and in particular: • Engage with and listen to children and families to improve services. • Continue TSH representation on South Lanarkshire Council Child Protection and Adult

Support and Protection Committees. • Update our Keeping Children Safe and the Adult Support and Protection Policies. • Update the training materials for the ½ day workshops in line with the relevant policies being

updated.

9.5 Healthcare Associated Infection (HAI) Management and control of infection, and the need to maintain a clean environment, are ministerial priorities. There is already strong compliance with NHS HIS infection control standards. The priorities for 2016/17 are: • Maintaining compliance with Health Facilities Scotland joint infection control / facilities

cleanliness monitoring programme. • Ensure compliance with the Health Improvement Scotland HAI Standards: February 2015. • Ensuring we use HEI Inspections as a vehicle for improving and developing Infection Control

systems and practices. • Continue to monitor against our “Vale of Leven” action plan. • Maintaining compliance with Scottish Government HAI reporting framework. • Increasing the cleanliness champion’s programme uptake among Senior Nursing Staff to

further embed control of infection and cleanliness within the ward environment. • Continue to support staff to undertake Food Hygiene training to a level commensurate with

their role. Supporting senior charge nurses and housekeeping staff in the ongoing audit and monitoring activities to maintain high standards.

9.6 Clinical Governance Clinical Model principle 9: clinical governance strengthens and informs care Staff will demonstrate a commitment to adopting best practice and to share new learning that supports service improvement. The organisation will promote and deliver the research and clinical effectiveness agenda and monitor the performance of our services against agreed indicators. We will learn and develop from past events and reflect on incidents, accidents, complaints and concerns in a way that is positive and transparent.

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In supporting this Clinical Model Principle, during 2015/16 we have: • Continued leadership walkrounds giving staff and patients improved access to senior staff

and a clear feedback/action loop on learning points raised. • Audited our documentation to ensure comprehensive care planning is undertaken and recorded. • Provided clinical governance reports to Hub Clinical Forums on a monthly basis. This

includes feedback on complaints and patient feedback; incidents and adverse events; and analysis of integrated care pathway data.

• Driven improvement through the Scottish Patient Safety Programme work streams. We are also now – for 2016/17: • Reshaping our business support structures and resources to deliver a strengthened focus on

quality assurance and quality improvement. • Continuing to refine our reporting processes as they relate to feedback and complaints, with a

focus on learning and improvement. • Re-auditing nursing care plans and ensuring they reflect assessed need and CPA treatment

care plan goals. • Further developing quantitative and qualitative measures through which we can gauge

service quality. The Hospital has a statutory responsibility to establish clinical governance arrangements which improve the quality of care and treatment for patients. The Hospital has done well in the assessment of compliance with good practice clinical governance arrangements. The Hospital’s approach to learning and development, clinical supervision, research and clinical effectiveness all support the drive to improve the quality of service delivery. 9.7 Achieving Results through Teams

Clinical Model principle 6: strengthen multidisciplinary working Staff will adopt new ways of working that ensure communication and joint working are maximised and they will be committed to service improvement that crosses traditional professional boundaries. Staff will fully understand their contributions to the new Clinical Model and know how they play their part in achieving the organisation’s goals. In supporting this Clinical Model Principle, during 2015/16 we have: • Tested and evaluated integrated models of working between the Hubs and Skye Centre as

part of the patient day project. • Introduced a more integrated model of working between the patient involvement team and

complaints department. • Tested a model of arts therapy services being ‘hosted’ by Psychological Therapy Services. We are also now – for 2016/17: • Reviewing the clinical service delivery model and opportunities to promote integrated working

across departments. • Testing opportunities for the delivery of co-produced approach as part of the focus on

delivering activity for and with our patient group. • Describing the opportunities for new roles that work across professional boundaries, as part

of our workforce planning activity. We will continue to strive to ensure maximum multi professional participation in our case reviews. The expected standard is for 100% nursing attendance, and 80% attendance of key (or associate) workers. The Hospital continues to operate with individually specified levels of attendance of other professionals at case reviews, monitoring and reporting all of this activity against agreed standards. These initiatives also serve to support the TSH Quality Commitments: • Commitment 3 “Improve MDT working by providing organisational development support

through recognised tools for assessing culture”. • Commitment 8 “Develop the role of the Key Worker to improve impact on the experience of

the patients”. Page 22 of 40

10 Effective – Health Improvement The ultimate aim is to meet patients’ mental health needs, enabling, when appropriate, the patient to move onto another setting. Patients often have very significant physical health needs (related to risk taking behaviours such as substance misuse; or consequences of treatment over a prolonged time in institutional care); or are living with the effect of long term conditions. There are many contributory factors involved such as: lack of exercise, obesity, complications of psychotropic medication, and the consequences of a self-selected poor diet. In December 2011 the Hospital became a smoke free environment. An outcomes based approach to health improvement is being implemented with the assistance of NHS Health Scotland. Outcomes models have been developed for two of the three health improvement areas and these have been used to develop the performance framework for 2016/17. Clinical Model principle 8: comprehensive mental and physical health care and treatment All care whether for mental disorder or physical health and wellbeing will be delivered and reviewed through the care planning process. Staff will understand and deliver a health promotion and rehabilitative approach in their daily work with patients. In supporting this Clinical Model Principle, during 2015/16 we have: • Improved the healthcare environment significantly in the new Hospital, for example there is

better access to hub-based psychological therapies and hub-based exercise equipment. • Improved the reporting of Mental Health Outcomes for patients. We are also now addressing – for 2016/17: • Implementation of additional therapeutic milieu interventions, training staff and evaluating

outcomes from these developments. • Ways in which to provide patients with the necessary support, education and information that

enables them to make healthy choices to maintain and promote their own physical health. • More robust data recording methods of physical health activity, interventions and outcomes. • Health Promotion events will continue to be scheduled throughout the coming year delivered

by Health Centre Staff, covering areas such as Men’s Health Awareness, Staying Safe in the Sun, Bowel Screening and Dental Hygiene.

• VISION system was successful implemented within the Health Centre and is now a fully operational and live system which enables clinicians to access current physical health records for our patients including access to medical results. This is a more robust data recording method of physical health activity, interventions and outcomes.

10.1 Mental Health The Hospital uses a variety of measures to indicate the effective management of mental health at an individual patient level: • The ability to agree discharge / transfer safely to another setting. • Patterns and trends of historic risk information such as violent and aggressive behaviour. • Improvement in the BEST (Behavioural Status) nursing index score, and in the PECC

(Psychosis Evaluation tool for Common use by Caregivers). • Improvement in the formulation and management of risk profile of patients. Reduction in

dynamic risk factors can be demonstrated on the clinical and risk items of the regularly updated HCR20 assessments.

• For intellectual disability patients a more dynamic measurement of progress in relation to the management of risks is evidenced through the DRAMS (Dynamic Risk Assessment and Management System) tool. This assessment should be reviewed at minimum, monthly, by the key worker.

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• The psychology service is utilising the CORE (Clinical Outcomes for Routine Evaluation) system (purchased in 2011) which is a short self-report measure of mental health and wellbeing outcomes that will be used nationally to evaluate psychological therapies.

• Reduction in frequency and intensity of levels of observation. • Individual patients being assessed fit for grounds access whether full or partial. • Monitoring of agreed mental health outcome measures. 10.2 Physical Health The Hospital remains concerned to ensure that patients are encouraged and supported to adopt a healthy lifestyle particularly in relation to smoking, activity, and nutrition. Proactive assessment of significant risk factors can lead to improved outcomes for long term conditions. An approach which supports self management is crucial to a better long term outcome, which means that education plays an important part in improving health. • In December 2011 the Hospital became a smoke free environment. • The percentage of patients with an unhealthy weight is currently 85%. This is 20% above the

national average. A range of interventions are available to patients with unhealthy weight including Slim-Trim, Patients Healthy Living Group and Balanced Diet Workshops. A Health Psychologist is in post delivering an evidence based intervention to support achieving a healthier weight.

• Following the legal challenge around food restrictions, the Hospital continues to work towards mutually acceptable solutions in relation to changing patient behaviours around food and food purchasing. A major consultation exercise was undertaken in 2015, with recommendations made to The Board on a way forward.

• The recommendation for physical activity is 30 minutes a day, five days a week has recently been agreed through the physical health steering group, and will be monitored a s atartegt during 2016. It is one of the aims of the ongoing “patient’s day” project that increased levels of activity will be enabled. The number of places available in the sports department increased in 2015.

• A co-produced approach to activities related to physical health and well-being is an important element of this, with patients trained as sports leaders and having a role in delivering weight reduction interventions.

Diabetes In 2015, there were 23 patients with diabetes. The national prevalence is 4-5%, but the Hospital’s rate is 18%. Detection rates are enhanced through proactive screening and annual health reviews. Improved management is evidenced through the proportion of patients with fair to good glycaemic control (around 87% of those affected). Three patients have poor or very poor control. Coronary Heart Disease - Cardiovascular Risk Clinic In 2015, there were five patients with confirmed ischemic heart disease. Cardiovascular risk factor assessment helps identify those patients most at risk of possible future cardiac events and provides an opportunity to discuss lifestyle changes to reduce this risk. A key activity is to enable patients to make life style choices based on sound evidence and information. Risk assessments are offered to all patients over the age of 40 years and those patients presenting with other risk factors such as abnormal lipid profiles, raised blood pressure or any other risks. The ASSIGN risk assessment tool is used to assess the level of risk. The number of patients presenting month on month with such risk factors varies. 36 patients (29%) taking statin therapy are considered to have an increased risk of developing ischemic heart disease. Respiratory disease In 2015, there were 15 patients receiving treatment for diagnosed respiratory disease. Ongoing maintenance is evidenced through regular monitoring, assessment and intervention by the practice nurse, focusing on medication and inhaler use.

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Screening • The Hospital actively promotes anticipatory care, offering an annual health check to all patients. • A key challenge in 2014/15 was to continue to improve the uptake of the new colorectal

screening programme – five out of 28 eligible patients have submitted samples to date, all with negative results, together with four, also with negative results from the previous year.

• Retinopathy screening has continued since being re-established in 2012 – this was offered to all patients, and none have been identified as having diabetic retinopathy.

Some patients returning from general hospitals require extensive assistive equipment and physical rehabilitation which is co-ordinated, delivered and monitored by the allied health professionals. 10.3 Educational Attainment Patient learning is an integral part of the patient experience, through a broad range of activities (attachments to the education department, attendance at off ward therapeutic activities, as well as ward based activities). KPIs cover core skills screening, participation rates, and attainment rates. Some of the recent achievements in 2015 include: • A total of 54% of patients engaging in formal learning activities during 2015. • At end of December 2015, 106 patients had been invited to complete the core skills screening

process. There was an uptake of 92 patients. • For the patients screened in 2015, 84% have literacy skills at the functional level of Access 3

or above and 72% have numeracy skills at the functional level of Access 3 or above. • 52 core skill completions were completed during 2015 • In relation to the LDP target to support improvement in patients’ educational attainment and

life skills through enhancement of literacy and numeracy skills level, there were 20 core skill progressions during 2015. This brings the total number of progressions since the target was introduced in April 2009 to 58 (41 progressions in numeracy and 17 in literacy). o 7 patients progressed from Access 2 to Access 3 in numeracy o 5 patients progressed from Access 3 to Intermediate 1 in numeracy o 2 patients progressed from Intermediate 1 to Intermediate 2 in Numeracy o 3 patients progressed from Access 2 to Access 3 in literacy o 3 patients progressed from Access 3 to Intermediate 1 in literacy

• 12 distance-learning programmes were completed during 2015. • Two themed learning courses took place in 2015 – a Scottish heritage communications group (in

which learners achieved Level 3 Communications) and a Natural Wonders of the 7 continents group (in which learners who took part achieved Intermediate 1 Communications qualifications). The programme comprised learning that was open to all patients and each consisted of a 10 week course. This initiative continues to be was part of our aim to increase themed and group learning programmes. In 2016, we have agreed to implement two themed learning courses – “The Anne Frank Course” and “The UEFA European Championship course”.

• The Patient Learning Centre gained approval to deliver the Practical Woodcraft and Sports Leadership UK courses. The development of these qualifications allowed increased opportunities in 2015 for embedding of core skills qualifications across vocational areas (e.g. woodcraft and Sports). 5 patients are currently undertaking the Woodcraft qualification and 6 patients completed the Sports Leadership qualification

The key aims for 2016 onwards include: • Continuing to embed core skills qualifications across activities, vocational areas and patient

worker roles. • Expansion of vocational learning programmes • Exploration of additional qualifications across vocational areas. • Increased delivery of short courses, taster programmes, themed events and group learning

programmes. Future developments will give cognisance to the recommendations and outcomes from the Patient Activity project.

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11 Effective – Governance The governance and management landscape is increasingly complex both nationally and locally. One of the Hospital’s local quality commitments is to improve meeting effectiveness but this is only a small part of what is required. The national Outcomes Framework and the national Quality Strategy are twin drivers towards more outcome based approaches rather than process based approaches. This section of the LDP focuses on the effective and efficient management of resources.

11.1 Governance and Management Arrangements There are three statutory governance strands for Boards and the governance structure is set up to deal with these through the Clinical Governance, Staff Governance and Audit Committees. Management is based around the clinical teams, reporting to the senior management team. A new and expanded model of leadership walkrounds was implemented in 2014/15 and continued through 2015/16 – involving the Executive Directors, the Senior Management Team, the Patient Safety Steering Group, and the non-executive Directors by invitation. Actions arising are followed up, and reviewed at later walkrounds and at SMT. Corporate document standards are in place to help streamline the flow of documentation, and the group and committee structures within the Hospital are regularly reviewed to streamline, rationalise and simplify meeting arrangements so that these are fit for purpose. The corporate risk register is reviewed in tandem with the LDP and appropriate linkages made. A full review of the Risk Register was undertaken in 2015/16, in consultation with non-executive directors, executive directors and senior management staff. A summary of the corporate risk register is contained in Appendix 3. These initiatives also serve to support the TSH Quality Commitments: • Commitment 4 “More effective, more efficient meeting arrangements”. • Commitment 6 “Increase the accessibility and visibility of the Senior Management Team and

the Non Executives”. 11.2 Workforce

Clinical Model principle 5: supporting staff It is recognised that working with this patient group will at times be demanding and difficult. Staff will be supported and developed to enable them to meet these challenges and a culture of learning and reflection will be recognised and embraced by our clinical leaders and our Hospital managers. The Staff Governance Standard provides the organisation with a platform to drive improvements in the management of staff. Our staff governance action plan identifies important actions we plan to take to ensure that the five objectives of the standard are met.

The staff governance action plan includes plans to achieve national targets such as: • Management of sickness absence within 5% (4% national standard). • All staff will have an annual Personal Development Planning and Review meeting with their

line manager.

In addition to working towards the achievement of these standards, there are a number of local priorities which are important for 2015/16. A review of the workforce has commenced in 2015/16 designed to assess the fitness of the workforce profile for the current and future Hospital environment. A Joint Workforce Planning event was held and from this a number of workstreams were identified. These link to the objectives outlined within the 2020 vision with specific workstreams as detailed below:

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Sustainable Workforce; • To review nursing workforce capacity in relation to core workforce requirements • To review AHP workforce and leadership arrangements • To review the Clinical Model • To review the Patient Day • To improve Staff Attendance

Capable Workforce:

• To develop a Leadership Programme to nurture leadership skills and support workforce capability

• To develop secondment opportunities within the Forensic Network Quality Improvement Skills:

• To Develop a QI Strategy Effective Leadership:

• To develop recommendations to improve the nursing management and leadership arrangements

The review will be conducted in partnership and will take into consideration the mix of professional skills required to work with the patient population, and ensure that the Clinical Model can be successfully delivered in the short, medium and long term. In line with the 2020 workforce vision for NHSScotland, adoption of the national values will be progressed. This will include promotion of these values to ensure that they drive the decisions we make and the way our staff interact with each other. These initiatives also serve to support the TSH Quality Commitments: • Commitment 5 “Approach to personal development which is reflective and embedded”. • Commitment 7 “Ensure an effective range of mechanisms are in place that allows staff to

raise issues of concern that are then dealt with confidentially”. 11.3 Finance The financial plan set out the resources available to the Hospital and how these will be used. The table below contains an extract of the three year financial plan and main assumptions, pressures and risk, behind the plan, are in the following section. It is expected that we will have to submit a 5 Year Plan but these figures will form part of the final LDP.

LDP 3 Year Plan 16/17 17/18 18/19

Income £'k £'k £'k Core RRL 32,623 32,964 33,309 Non-core RRL 2,485 2,380 2,551 Non-core RRL AME 0 104 110 Income 1,504 1,519 1,535 36,612 36,967 37,505

Expenditure Pay 29,588 30,049 30,515 Capital Charges 2,485 2,380 2,551 AME Provisions 0 104 110 Non-Pay 5,368 5,422 5,476 Central Reserves 691 697 703 Savings (1,521) (1,685) (1,851) 36,612 36,967 37,505

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11.3.1 Overall position • The financial plan is balanced and delivery of a breakeven position during 2016/17 remains

dependent upon realisation of the savings plan. Financial risks remain high around the workforce plan skill mix.

• The plan is based on the indicative budgets set by the Scottish Government. • Savings targets continue to be challenging. • Current assumptions indicate the full FBC savings have been achieved, at the level agreed.

11.3.2 Funding As the public sector as a whole face funding cuts, the NHS has had some protection. This year the recurring increase in funding equates to 1.00%. With planned payroll increases, incremental drift, and an increase in NI contributions, close budgetary scrutiny is required in order to cover the inflationary increases faced in other additional running costs and the required savings. 11.3.3 Savings and FBC Handback The FBC savings, except the £100k pay back due in 2016/17; have been achieved, in line with the £1,804k Scottish Government assumption. At this draft stage the savings have not yet been split by detail, only by total and Recurring or Non Recurring, as meetings with Directors to negotiate savings are currently being held. Saving Scheme Details 16/17 17/18 18/19

Rec £000s

Non-Rec

£000s Total £000s

Rec £000s

Non-Rec

£000s Total £000s

Rec £000s

Non-Rec

£000s Total £000s

Efficiency & Productivity Workstreams Service productivity 0 0 0 Drugs and prescribing 0 0 0 Procurement 0 0 0 Workforce 0 0 0

Shared services

HR 0 0 0 Facilities 0 0 0 Other 0 0 0

Support services (non-clinical) 0 0 0 Estates and facilities 0 0 0 Unidentified savings 532 989 1,521 590 1,095 1,685 648 1,203 1,851 Total In-Year Efficiency Savings 532 989 1,521 590 1,095 1,685 648 1,203 1,851

There are continued efficiency and productivity improvements sought which will be identified, managed and implemented through this period. Savings targets for 2016/17 are particularly challenging as the Hospital manages the pressures noted below. 11.3.4 Pressures There are a number of pressures facing the Hospital over the coming year: • Workforce Plan Numbers and Skill mix – Due in part to the fall in staff turnover, it has not yet

been fully possible to achieve the planned workforce numbers set out in the Full Business Case. We have met the year-on-year targets to date. The issues relate mainly to Nursing and Skye Centre costs. The full workforce plan is currently under review, to be concluded in 2016.

• Increased payroll costs with regard to pension and National Insurance contributions which come into effect in 2015/16 and 2016/17.

• Utility costs continue to rise, giving both a price and usage pressure in 2016/17. • There are a number of costs associated with the new Hospital – for example replacement

furniture and carpets and general repairs, this is monitored closely and outturns adjusted accordingly. Ongoing evaluation of this impact over the coming years is being assessed in order that budgetary pressures can be controlled.

Page 28 of 40

There are a number of risks associated with the 3-year plan:

• Savings plans – as stated above the operational running costs of the site are more than

planned. A savings plan around the workforce, capital charges and supplies has been drawn up; however additional savings may need to be made if the on-going costs are more than forecast. Also year on year it gets harder to identify workforce savings without impacting on patient care or security. If plans fall behind the financial balance could be at risk unless other non pay savings can be found.

• The reduction in capital funding potentially leaves equipment replacement at risk, as the formulae allocation will require close control and review to be able to cover any major equipment replacement programmes.

11.4 Property and Assets The performance of assets is seen as critical by the Hospital. In order for the Hospital to meet its strategic objectives it is essential that existing and planned investment is targeted and effectively utilised. The Property and Asset Management Strategy (PAMS) reflects the following aims: • To maintain and develop a high quality, sustainable site and assets that support the provision

of high quality forensic mental health care in appropriate and secure facilities. • To ensure that the operational performance of assets is appropriately recorded, monitored,

reported and reviewed and, where appropriate improved. • To ensure an effective asset management approach to risk management and service

continuity.

11.5 eHealth and Information Governance eHealth and Information Governance aims are driven by the local corporate objectives and the national strategies. This is encapsulated within the hospital’s eHealth Delivery Plan. This has been tailored to reflect the national strategy and local requirements, and is reviewed annually by eHealth and the Scottish Government Heath and Social Care Directorate. The areas of investment until 2017 will still be directed towards 4 of the six strategic aims defined in the NHSScotland eHealth Strategy: • Efficiency led IT investment programme. • Clinical information. • Medications management. • Real time management information. The eHealth delivery plan has an outcomes based approach reflecting the expected care or service outcomes as defined in the NHS Scotland Quality Strategy, the eHealth delivery method or actions and associated targets / measures. We have been working to indentify a cost effective replacement storage and backup solution. This work has been ongoing for some time and a solution has now been identified. A test of systems will be used to ensure the final recommendation meets the required specifications while taking note of present budgetary restrictions. In 2015/16, we started to consolidate our network storage and remove duplicate data. This extensive project is still ongoing into 2016/17 and – once completed – will provide additional storage without additional cost. A robust IG program is in development to ensure new and existing systems meet all relevant national and local governance requirements. Guidance on time limits for the retention of data will be developed in conjunction with the hospital. This plan will ensure that reasons for retaining data are legitimate and that retained data is only used for the intended purposes. Data sharing agreements with partner organisations will be implemented ensuring a robust approach to Data management and sharing.

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There have been ongoing discussions between partner organisations regarding the use of the Electronic Patient Record (“EPR”) for recording patient information. This is progressing and it is expected that an agreement on the sharing and ownership of data will be signed off shortly. The creation of a data warehouse within the hospital is under investigation and review. This will provide centralised and controlled access to the data needed to deliver effective and efficient patient care. Business Intelligent Tools will be researched and a suitable solution will be procured to facilitate data access via dashboards displaying data specific to staff requirements. The State Hospital is working as part of a national project looking for an end to end electronic prescribing & medicines administration system. This will identify and deliver a suitable medications monitoring system that will bring clinical benefits by providing accurate and up to date locally defined drug databases, patient specific alerts such as overdose warnings and allergy alerts. The organisational benefits with this system will be computerised entry and management of prescriptions, and a robust audit trail for the entire medicines process. This will facilitate centralised monitoring of dispensed medications with the intention of developing a feed into the main EPR system. A single sign-on solution is presently under rollout across the Hospital. This complements the development of our IG improvement program by reducing the exposure of login details that could have previously been written down and stored in desks. This system provides the secure electronic storage of multiple passwords for the electronic system used on-site. The Hospital’s wireless network continues in the process of development. This resource when completed and fully utilised will continue to reduce the need for printed documentation and in future will support a range of hand held devices for use by Facilities, Estates and clinical staff. More detail and further information relating to specific outcome and measures can be found in the Hospital’s eHealth Delivery Plan. 11.6 Procurement The proper management of procurement is an important factor contributing towards the efficient operation of The State Hospital and the attainment of its corporate objectives. In order to support steps already underway to deliver better healthcare, it is vital to staff and patients that products and services are delivered of the highest quality and at optimum value. Systems used for procurement must be user friendly and tested as fit-for-purpose at point of use, whilst managing risk and due diligence. The State Hospitals Board for Scotland currently spends over £2.4m on non-pay items. This Local Delivery Plan positions procurement activity visibly within the organisation, linking the procurement function to Board level. The Finance and Performance Management Director, ensures the involvement of the management of the Board’s procurement deliverables are maintained at appropriate levels within the organisation. The Procurement Strategy sets out clear, measurable objectives and priorities for improvement which will be closely monitored. Progress against strategic objectives will be reported to The State Hospitals Board for Scotland through the revitalised Procurement Steering Group. The Procurement strategy addresses key procurement issues and is subject to annual review. All Procurement activity is also subject to review from the board’s Audit Committee on an annual basis.

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11.7 Sustainability Cutting carbon emissions as part of the fight against climate change is a key priority for all public bodies. The Scottish and UK governments have identified the public sector as key to delivering carbon reduction across Scotland and the UK, in line with Kyoto commitments and the world-leading Scottish and UK Climate Change legislation. The Hospital has developed a Sustainability Action Plan and a Carbon Management Programme which are ensuring that sustainability becomes embedded in our way of working and decision making. The operation of a biomass boiler has made significant savings in both CO2 emissions and energy consumption. The Hospital continues to investigate the viability of a wind turbine on-site, and of other renewable energy options, which have the potential to make a strong contribution towards increasing energy efficiency. The Hospital’s Sustainability Development Group meets bi-monthly to review the Sustainability Action Plan and to monitor progress against this and towards Greencode compliance. Senior staff are also regular participants at the NHSScotland Sustainability Steering Group, from which monitoring actions continue to be identified. With the required statutory reporting due in late 2016 for the Public Sector Climate Change Duties Reporting Template, the Hospital will be submitting a draft template for 2015 in advance of this, in order to receive feedback on progress against national targets and reporting. 11.8 Innovation The State Hospital is committed to innovative ways of working and developing. An Innovation lead will establish a team to raise awareness and provide opportunities to develop in this area throughout the Hospital. This will ensure that the Board has input to national initiatives such as procurement, and contributes to the sharing of innovative concepts with other Health Boards in Scotland. 11.9 Equality, Diversity and Rights The Scottish Parliament introduced the Equality Act in 2010 which provides a new cross-cutting legislative framework to protect the rights of individuals and advance equality of opportunity for all; to update, simplify and strengthen the previous legislation; and to deliver a simple, modern and accessible framework of discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society. The Act is a major simplification of discrimination legislation that makes the law easier to understand and comply with and delivers significant benefits for businesses, public bodies and individuals. Hospital information systems monitor equality and diversity issues for all stakeholders and these measures are all embedded within the Involvement and Equality Service KPI framework. In line with the new legislation, the Board has developed and approved a set of Equality Outcomes. These were developed and prioritised in consultation with all stakeholders and these will continue to be addressed through 2016/17. They include: • Increasing patient involvement in CPA review process. • Ensuring policies on recruitment / selection, equal opportunities, and dignity at work all reflect

national PIN guidelines. • Increasing carer input to case review process and patient care generally. • Increasing access to spiritual and pastoral care beyond religious services. • Monitoring quality of performance to the revised Equality Impact Assessment process. A review is underway in relation to the current Recruitment Policy in partnership and in line with the revised PIN on Safer Pre and Post Employment Checks.

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http://www.opsi.gov.uk/acts/acts2010/ukpga_20100015_en_1

APPENDICES

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Appendix 1 Quality and Performance Measurement Framework

HEALTH IMPROVEMENT – Improving healthy life expectancy and encouraging healthy lifestyles Corporate Objectives

• To treat patients’ mental illness and disorder, manage the risks posed by patients, and ultimately, where possible, enable patients to be transferred / discharged.

• To help patients sustain and improve their physical health. • To improve patients’ educational attainment and life skills.

Clinical Model Principles • Principle 8 - Comprehensive mental and physical health care and treatment. Outcome Measures • Improved physical and mental wellbeing. • Reduction of risks to self and others. • Sustainable transfer. • Reduced incidence of metabolic syndrome. Targets • 100% of patients have their care and treatment plans reviewed at 6 monthly intervals. • 90% of patients will be engaged in psychological treatment. • 90% of patients will be engaged in off-hub activity centres. • 90% of patients will be offered an annual physical health review. • 60% of patients will undertake 90 minutes of exercise each week. • 25% of patients will have a healthier BMI.

Supporting Measures / Quality Improvement Data • Proportion of patient engaged in hub activities. • Monitoring of CORE outcome scores for psychological therapies. • BMI and waist circumference trends. • Engagement in weight intervention programmes. • Grounds access / fresh air monitoring. • Uptake of physical health screening programmes. • Uptake of vaccination programmes. • Proportion of patients with nutritional care plan. • Engagement in educational activities.

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EFFICIENCY & GOVERNANCE IMPROVEMENTS - Continually improving efficiency and effectiveness Corporate Objectives

• To ensure robust and proportionate governance and management arrangements are in place. • To continually improve the effective and efficient management of resources.

Clinical Model Principles • Principle 5 - Supporting Staff. Outcome Measures • Operate within resource limits; meet cash requirement.* • Sustainable recurrent financial balance. • Demonstrable best value. Targets • 5% sickness absence.* • 3% reduction in CO2 emissions for fossil fuels.* • 1% reduction in energy consumption.* • 100% of staff have an approved PDP. Supporting Measures / Quality Improvement Data • Use of overtime. • Efficiency savings. • Number of staff with PDP in last 12 months. • Alignment with Workforce Plan.

*national target

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ACCESS TO SERVICES – Patients have quicker, easier and greater use of services Corporate Objectives

• To operate effectively with partners, providing seamless care, in agreed pathways, ensuring patients’ length of stay in the Hospital reflects their care and treatment requirements.

• To ensure better and faster access to services provided by and for the Hospital, increasing patients participation in clinical activities, within the parameters of appropriate level of security.

Clinical Model Principles • Principle 1 – Integration. • Principle 3 – Individualised Care Pathways. Outcome Measures • Reduced time delays in discharge / transfer. • Improved patient experience. Targets • 100% of patients transferred / discharged using CPA. • 100% of patients requiring primary care services will have access within 48 hours. • 100% of patients will be commence psychological therapies <18 weeks from referral date. • 100% of patients will engage in meaningful activity on a daily basis.

Supporting Measures / Quality Improvement Data • Proportion of patients with a therapeutic timetable. • Number of sessions of activity undertaken by patients each week. • Number of planned Skye Centre activities not attended. • Skye Centre closures. • Number of planned hub activities. • Number of planned hub activities cancelled. • Admission & Discharge / Transfer waiting times.

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TREATMENT APPROPRIATE TO INDIVIDUALS – Patients receive high quality services that meet their risks and needs, and which maintain public, staff and patient safety. Corporate Objectives

• To improve the quality of the patients experience, increasing the engagement of patients in care and treatment planning and in the delivery of high quality services.

• To minimise the adverse impact of patient behaviour on others. • To provide evidence based, expert, multi-professional, safe and effective care, increasing

engagement of professionals with patients and carers, in the delivery of high quality services

Clinical Model Principles • Principle 2 – Patient Focussed Care. • Principle 6 – Strengthen Multi-disciplinary Working. • Principle 7 – Violence Risk Assessment and Management. • Principle 9 – Clinical Governance Strengthens and Informs Care. Outcome Measures • Demonstrable Improvements in patient experience including monitoring of patient attendance

at case review. • Improved visitor experience. • Reduction in volume and impact of assaults. • Demonstrable improvements in multi-professional working. Targets • 100% of patients have their clinical risk assessment reviewed annually. • 100% of hubs have a monthly community meeting. • Agreed levels of attendance by all clinical staff at case reviews (medical, nursing key worker,

psychology, social work, pharmacy, security, occupational therapy and Skye Centre staff). Supporting Measures / Quality Improvement Data • Proportion of patients with a psychological formulation. • ICP Completion rates and variance analysis data e.g. completion of nursing assessments;

patient / carer involvement in case reviews; report preparation. • Monitoring of therapeutic milieu. • Comments, Complaints, Compliments, Concerns (4Cs). • Annual surveys – patients, carers and staff. • Datix information e.g. proportion of very high and high risk incidents; shift from assault to

behaviour incidents. • Reportable injuries (RIDDOR). • Compliance with security standards. • Clinical supervision. • High dose / multiple antipsychotic medication monitoring. • Volume and type of patient contact by professional staff. • Restrictions (mail, telephone). • Equality and diversity monitoring. • Adult protection. • Child protection and child visits. • Advocacy key performance indicators. • PMVA data – PAA activations, seclusion, restraint, drug testing, observation etc. • Compliance with registration requirements. • Clinical supervision. • Cleaning specification compliance.

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Appendix 2 Summary Corporate Risk Register – updated register to be included

Category Risk Initial Risk

Grading (Workshop)

Current Risk Grading

Target Risk Grading Owner Next Scheduled

Review Governance Committee

Patient Experience

Potential adverse event impact arising from clinical presentation out of hours with no doctor on site

Unlikely x Moderate

Unlikely x Moderate Unlikely x Moderate G Brechin July 2015 Clinical

Governance

Patient Experience

Failure of staff to utilise available evidence and best practice in making clinical decisions

Unlikely x Moderate

Unlikely x Moderate Rare x Moderate L Thomson June 2015 Clinical

Governance

Patient Experience

Failure to protect vulnerable patients Possible x Major Possible x Major Unlikely x Major S Milloy June 2015 Clinical

Governance

Patient Experience

Failure to implement the clinical model Possible x

Moderate Possible x Moderate Unlikely x Moderate S Milloy June 2015 Clinical

Governance

Patient Experience

Failure to protect children Unlikely x Major Unlikely x Major Unlikely x Major S Milloy June 2015 Clinical

Governance

Patient Experience

Failure to have integrated record available Possible x

Moderate Possible x Moderate Rare x Minor S Milloy July 2015 Clinical

Governance

Objectives / Project

Inadequate use of available data or absence of data required for effective decision making at senior management and non executive level

Unlikely x Moderate

Unlikely x Moderate Unlikely x Moderate R McNaught August 2015 Audit

Injury Failure to assess and manage the risk of aggression and violence effectively

Possible x Major Possible x Major Possible x Major S Milloy June 2015 Clinical Governance

Service / Business Disruption

Inadequate emergency or business continuity planning - fit for purpose incident command arrangements

Unlikely x Major Unlikely x Moderate Unlikely x Moderate D Irwin June 2015 Audit

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Grading (Workshop)




Service / Business Disruption

Risk of serious security incidents Unlikely x Major Unlikely x Major Unlikely x Major D Irwin June 2015 Audit

Staffing and Competence

Failure to implement and continue to develop the workforce plan to be responsive to changing circumstances.

Unlikely x Moderate

Unlikely x Moderate Unlikely x Minor B.A.Nelson July 2015 Staff Governance


Failure to meet staff governance standards Unlikely x

Moderate Unlikely x Moderate Unlikely x Minor B.A.Nelson June 2014 Staff Governance


Failure to have effective policies and procedures in place and used by staff

Unlikely x Moderate

Possible x Moderate Rare x Moderate G Brechin August 2015 Audit


Impact of breakdown of Industrial relations Possible x Major Unlikely x Major Rare x Minor B.A.Nelson December 2014 Staff Governance


Failure to consider work related driving risks Possible x

Moderate Possible x Moderate Rare x Minor M Richards April 2015 Audit


Failure to adhere to policy regarding mandatory training refresher requirements

Likely x Moderate

Likely x Moderate Unlikely x Minor B.A.Nelson March 2015 Staff Governance

Financial

Failure to recognise or attain sufficient resources and manage these to deliver the planned objectives

Unlikely x Major Unlikely x Major Unlikely x Moderate G Brechin August 2015 Audit

Financial Failure to achieve required efficiency savings and failure to work within available resources

Unlikely x Moderate

Unlikely x Moderate Rare x Moderate R McNaught March 2015 Audit

Inspection / Audit Inadequate compliance with CELs and other statutory requirements

Unlikely x Moderate Rare x Moderate Rare x Moderate G Brechin July 2015 Audit

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Grading (Workshop)




Inspection / Audit Failure to utilise appropriate systems to learn from prior events internally and externally

Possible x Major Possible x Moderate Unlikely x Moderate G Brechin July 2015 Audit

Adverse Publicity / Reputation

Absconsion of Patients Unlikely x Major Unlikely x Major Rare x Moderate L Thomson July 2015 Audit


Risk of Security breaches Unlikely x Moderate

Unlikely x Moderate Unlikely x Moderate D Irwin June 2015 Audit


Failure to have effective Data Protection and eHealth security arrangements in place

Unlikely x Moderate

Unlikely x Moderate Rare x Moderate R McNaught May 2015 Audit


Deliberate Leaks of Data Possible x Major Possible x Major Unlikely x Moderate G Brechin May 2015 Audit

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Appendix 3 Glossary of Terms AfC Agenda for Change (pay arrangements and terms and conditions for the majority of NHS staff) AHP Allied Health Professionals AME Annually Managed Expenditure BEST Behavioural Status CACR Computer Assisted Cognitive Rehabilitation CORE Clinical Outcomes for Routine Evaluation CPA Care Programme Approach DRAMS Dynamic Risk Assessment & Management System ECDL European Computer Driving Licence EPR Electronic Patient Record FBC Full Business Case GIRFEC Getting it right for every child HAI Hospital Acquired Infection HCR-20 A tool to manage risk of violence assessment and planning (Historical Clinical Risk -20) HEI Healthcare Environment Inspectorate HIS Healthcare Improvement Scotland ICP Integrated Care Pathways IM&T Information Management & Technology KSF Knowledge and Skills Framework (part of Agenda for Change) KPI Key Performance Indicator LDP Local Delivery Plan MAPPA Multi Agency Public Protection Arrangements MCN National Forensic Managed Care Network MDT Multi-disciplinary Team MHDP Mental Health Delivery Plan NHS National Health Service PAA Personal Attack Alarm system PAMS Property and Asset Management Strategy PDP Personal Development Plan PECC Psychosis Evaluation tool for Common use by Caregivers PFPI Patient Focus Public Involvement PIN Partnership Information Network PLC Patient Learning Centre PMVA Prevention and Management of Violence and Aggression PPG Patient Partnership Group RIDDOR Reporting of Injuries, Disease and Dangerous Occurrences Regulations RMA Risk Management Authority RRL Revenue Resource Limit SGHSCD Scottish Government Health and Social Care Directorate SIGN Scottish Inter-collegiate Guideline Network SMT Senior Management Team TSH The State Hospital WTE Whole Time Equivalent

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 25 February 2016 Agenda Reference: Item No: 15 Sponsoring Director: Finance and Performance Management Director Author(s): Finance and Performance Management Director Head of Management Accounts Title of Report: Financial Position 1 SITUATION This paper is to inform the Board of the financial position to 31 January 2016. 2 BACKGROUND A high level overview of the financial position to date for both Revenue and Capital is provided in this report. 3 ASSESSMENT Revenue position

Capital Position

4 RECOMMENDATION The Board is invited to note the following:

• The year to date position is favourable for Revenue and Capital and it is anticipated that both will be in a breakeven position for the year end.

Page 1 of 2

MONITORING FORM


Monitoring of financial position

Workforce Implications No workforce implications – for information only.

Financial Implications No financial implications – for information only.

Route To Board Which groups were involved in contributing to the paper and recommendations.

Head of Management Accounts.



Assessment of Impact On Patient Experience

None identified.

Equality Impact Assessment No identified implications.

Page 2 of 2

THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 25 February 2016 Agenda Reference: Item No: 15 Sponsoring Director: Finance and Performance Management Director Author(s): Finance and Performance Management Director Head of Management Accounts Title of Report: Finance Report as at 31 January 2016 1 BACKGROUND

1.1 The Revenue and Capital plans, and financial monitoring, are considered by the Senior Team and the Board. This report provides information on the financial performance to 31 January 2016.

1.2 The three year financial plan for 2015/16 – 2017/18 is an integral part of the Board Local Delivery Plan (LDP). The LDP is the strategic plan which sets out the agreed vision for service delivery and development for the Board, and sets out a balanced budget for 2015/16 on the basis of achieving £1.342m efficiency savings, as referred to in the table in section 3. Savings targets budgets are recognised within the directorates at the start of the year and phased as twelfths – there may be a timing issue when savings are made and realised against these targets.

2 CURRENT SITUATION

2.1 Revenue Resource Limit Outturn

The Board is reporting an under spend of £0.044m to 31 January 2016. The “in-month” movement was an under spend of £0.017m, which is mainly to do with RHI monies not yet utilised. The current overall position is summarised in the table below –

Page 1 of 6

2.2

Outturn It should be noted that, due to the nature of the service provided by The State Hospital and the challenges which arise from the safe management of our patients, all nursing shifts which are scheduled on our wards and are then affected by sickness, high levels of clinical intensity and holiday absence, are filled; this therefore translates automatically into higher levels of overtime staffing, evident in Table 2.4 below. This differs from the general approach of territorial boards, which may be more able to accommodate a lower ward staff level in the same circumstances as they do not face the same risks to staff if numbers are short. Revenue Resources Revenue allocations received from Scottish Government (including anticipated) up to 31 January 2016 amounted to £35.042m, this is in line with the annual budget, there is still a final FBC hand back savings of £0.100m, although it is planned for 16/17 it is hoped to be affordable towards this year end.

2.3 General Manager Hospital Services The total budget for General Manager Hospital Services is £22.4m. This is the largest directorate in terms of staffing and budget allocation and is reporting an over spend of £0.322m at 31 January 2016.

2.4

The following tables give analysis of the cost areas within this directorate, for clarity it has been split three ways to reflect ownership and management of individual budget areas.

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GM: GM Over spend of £0.587m. Overtime and excess hours are included in the actual WTEs column. The main contributor of the over spend is Hub Nursing with an over spend of £0.743m, in 15/16 the overtime budget was increased to £0.300m. The Ward closure of Arran 3 and the reduction in night shift staffing in July 2014 did not result in the expected fall in nursing costs/overtime hours worked, which have shown only a modest 10% decrease (51,276hrs to 46,726hrs = 4,550 hours – compared to the expected reduction of approx. 40,000 per annum). The is principally due to the fact that since July 2014 there has been a significant and sustained rise in the levels of clinical activity. This clinical activity centres around staffing to -

i - cover patients boarding out at general hospitals and ii - cover patients who have an increased observation status (level 3s).

In relation to boarding out, there has been a 372% increase (2,088hrs to 9,864hrs) in the required staffing hours. In relation to Level 3 observations, the increase has been an average of 25% for daytime (3,218hrs to 4,014hrs) and 190% for nighttime (164hrs to 476hrs) per month – the combined annual effect being approx. 13,000 hours. Please note the reference period for these statistics is the 15 months period before and after July 2014 (April 2013-July 2014 and August 2014-October 2015) The over spend is partially offset by vacancies in Skye Centre, Dietetics and AHPs. H & C Admin variance is due to phasing of targeted savings, not achieved. Nursing Resource and Directors PA’s over spends are also attributable to phasing of targeted savings, also not achieved.

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GM: Security Under spend of £0.049m. Estates are over spent mainly to do with savings targets not achieved due to pressures mainly around repairs and escorts. Housekeeping is under spent mainly due to currently running with one ward closed due to reduction in patient numbers, and trying to cut back on cleaning of non clinical areas, to reach targeted savings. Laundry is due to fewer mattresses being bought now that through HAI Audits some are deep cleaned. Mailroom is also under spent to date; this was due to earlier vacancies. Utilities are under spent, mainly in connection with oil and gas usage. Kitchen is overspent mainly to do with targeted savings not being achieved. Staff restaurant is slightly under spent. GM: Psychology (CE) continues to run with vacancies, and fewer trainees than budgeted, giving rise to the under spend of £0.216m.

2.5 Medical Services The total budget for Medical Services is £2.3m. This directorate is reporting an under spend of £0.169m at 31 January 2016, which is mainly in connection with fewer Doctors in Training being recharged to TSH from other boards, and the benefit of an earlier vacancy (now recruited to). It is hoped we can carry forward some of this under spend to help with known pressures in 2016/17.

2.6 Nursing – Non Ward The total budget for Nursing – Non Ward is £1.1m. The under spend of £0.171m at 31 January 2016 is due mainly to staff vacancies and under spends in corporate training and divisional course fees.

2.7 2.8

2.9

Security Services The total budget for Security Services is £1.5m. There is an under spend of £0.020m as at 31 January 2016, mainly in connection with recurring savings of 2.00wte’s due to the benefits of a new rota implemented last year. Corporate Functions The total budget for Corporate Functions is £7.8m – reporting an under spend of £0.007m. The table below gives more detail –

This corporate area covers a number of the main support departments and significant corporate costs, including capital charges, which is showing an overspend to date, due to revision of capital charges since LDP sign off, and write off of eprescribing system.

Page 4 of 6

This also includes ‘central commitments’ monies which are monies not yet allocated to departments – for which much of the spend is committed later in the year. Misc Income is due to RHI Income and spend not in line with phasing of budget. The under spend in CE is mainly in connection with the timing of research spending. Finance under spend is mainly in connection with vacancies, offset with rates and legal claims pressures. Human Resources under spend is due to earlier vacancies and under spend in PVG spend in non pay.

3 3.1 3.2

EFFICIENCY SAVINGS TARGET

To balance the financial plan in 2015/16 the Board was required to release £1.342m of cash from budgets through efficiency savings. Savings will be recognised quarterly (following authorisation from Directors) and discussed at quarterly financial reviews. The savings for the first three quarters is £0.997m against the £1.054m LDP trajectory to January, shall consider changing the phasing in 16/17 to quarterly instead of monthly. The next savings will be reflected in March for Quarter four. It is expected we will realise these savings in the last quarter, mainly in connection with vacancy management. The table below demonstrates this.

The year to date savings achieved are shown by Directorate in the table below.

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4 4.1

CAPITAL RESOURCE LIMIT

The Board had an initial Capital Resource Limit of £0.300m – the table below illustrates this.

Capital resources will mainly be committed over the remaining few months of the year, in line with the capital priorities agreed with SMT, with input from the new Capital sub group.

5 CONCLUSION

5.1 5.2

Revenue It should be noted we plan to breakeven at the year end. All departments undergo ongoing scrutiny for identification of savings to be achieved in order to reach required targets, particularly to make them recurring. Monthly meetings between Head of Management Accounts and Directors/budget holders, with quarterly reviews involving the Finance and Performance Management Director allow negotiations for savings to be taken. A financial plan action list is also updated by the Head of Management Accounts following monthly budget meetings to eliminate any surprise element and to evaluate expected pressures and benefits to make the Chief Executive and Finance and Performance Management Director aware of the effects on the financial outturn; and to compare with the LDP trajectory. Capital

We may be slightly under spent (projected at around £10k), and it is hoped that we may be able to carry this forward.

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Date of Meeting: 25 February 2016 Agenda Reference: Item No: 16 Sponsoring Director: Chief Executive Author(s): Chief Executive Board Secretary Title of Report: International Travel Requests 1 SITUATION Requests for international travel require to be submitted to the Board for their approval. 2 BACKGROUND The following requests have been received. Line management approval has been given and costs are within budget. Flights and accommodation will be booked via procurement at the earliest opportunity to ensure best value arrangements are made.

EVENT/LOCATION

DATE

STAFF

INVOLVED

COST

International association of Forensic Psychotherapy (IAFP) 25

anniversary conference – Ghent

7 – 10 April

2016

Dr Adam Polnay,

Consultant Psychiatrist in Psychotherapy

*£760

(approx)

International Association of Forensic Mental Health Service (IAFMHS) Conference – New York

20 – 24 June

2016

Lindsay Tulloch

(Research Nurse)

Sandra McAllister (Lead Nurse)

Jamie Pitcairn (Research and Development

Manager)

Helen Walker (Consultant Nurse Forensic Network Senior Lecturer

UWS)

All *£1,900 (approx)

UWS will pay half the

expenses

* This includes conference fee, flights and accommodation.

Page 1 of 3

3 ASSESSMENT Many of the Hospital’s Consultants and other staff are asked to present at Conferences and this is an opportunity to share best practice with colleagues from other organisations and to raise the profile of the work carried out within The State Hospital. Few nurses are asked to present at conferences and this is also an opportunity to raise the profile of the nursing work carried out within The State Hospital and the Forensic Network. It is also important in encouraging a research and development focus within Nursing in the Hospital. The presentation at the IAFMHS Conference in June is ‘Nursing patients under difficult circumstances in a high secure environment; use of seclusion, self isolation and emergency response belts’. The IAFMHS covers a very broad range of topics, such as risk assessment and risk management, clinical interventions, evidence based practice, competencies, legal frameworks, policy development, service –user and carer initiatives and many more. Former attendance at this conference has led to the development of new working partnerships with colleagues in the Republic of Ireland and Adelaide, Australia. Research is also an important area of work in the Hospital. The IAFMHS conference offers the chance to engage with fellow professionals in the same field of work. In the case of the IAFP Forensic Psychotherapy Conference, the theme is people who have been violent towards family members, and how people respond to this violence. The aim is to increase understanding of this area and deepen skills for working therapeutically with patients who have been violent towards their families. The event also covers staff and societal responses to such patients and links directly to the role Dr Polnay has in leading Reflective Practice sessions for staff to try to help staff to respond in as therapeutic a way as possible to disturbed patients. Following attendance at various conferences and events staff will share the knowledge they have gained with their colleagues in the wider Hospital through assigned timeslots within the Journal Club lunchtime presentation meetings. In addition, any research presented at this conference will also be submitted to The State Hospital’s Annual Research and Clinical Effectiveness Conference. 4 RECOMMENDATION Members are asked to approve the request received for international travel.

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MONITORING FORM


Monitoring of spend of staff requests for International Travel related to sharing of best practice, training and development.

Workforce Implications N/A

Financial Implications Monitored against relevant budgets – budget in place for all requests received.

Route To Board Which groups were involved in contributing to the paper and recommendations.

Requests received by Chief Executive. Board Members to consider at their next meeting thereafter.


N/A

Assessment of Impact on Stakeholders

Learning shared across the organisation for the benefit of patient care.

Equality Impact Assessment No issues

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Minutes of the meeting of the Audit Committee held on Thursday 21 January 2016 at 9.45am in the Boardroom, The State Hospital, Carstairs. PRESENT: Non Executive Director Bill Brackenridge Non Executive Director Elizabeth Carmichael Non Executive Director Anne Gillian (Employee Director) Non Executive Director Maire Whitehead (Chair) IN ATTENDANCE: Internal Chief Executive Jim Crichton Board Chair Terry Currie Security Director Doug Irwin (part) Finance and Performance Management Director Robin McNaught HR Director Barbara Anne Nelson (part) Risk Management Team Leader Nicola Watt (part) Board Secretary Jean Wade External Director, Scott Moncrieff Karen Jones Auditor, KPMG Rachel Slaski Senior Manager, KPMG Matthew Swann 1 APOLOGIES FOR ABSENCE AND INTRODUCTORY REMARKS Apologies were received from Chris Brown, Scott Moncrieff. Maire Whitehead welcomed everyone to the meeting. 2 CONFLICTS OF INTEREST Jim Crichton declared that he had been appointed Non Executive Director of SACRO. This had been recorded in the Board Members’ Register of Interests. No other changes to Conflict of Interests were noted from those previously recorded. These would be held on record for the year. Any changes would be reported and recorded as they arose. 3 MINUTES OF THE PREVIOUS MEETING The Minutes of the previous meeting held on 17 September 2015 were approved by the Board at their meeting on 29 October 2015. 4 MATTERS ARISING AND ACTION NOTES UPDATE Matters Arising: There were no matters arising from the Minutes that did not feature on the agenda. Action Notes Update: Members noted that all Actions were progressing as required. Robin McNaught provided the following updates:

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Action No 1: The External Consultant costs in relation to work on the perimeter were currently around £15k. Subsequent work would be undertaken next year and, therefore, this sum would increase. Action No 3: The Post Project Review Report had been submitted to Scottish Government following the amendments made as discussed. 5 AUDIT FOLLOW UP REPORT Members received a report from Robin McNaught which provided an update on progress made to date with the implementation of audit recommendations. Members noted the current compliance rate with previous quarters which indicated that some progress had been made with improvement in the number of recommendations being completed. Robin McNaught summarised the progress against existing audit reports. Members discussed a number of areas of the report in relation to the KPMG Review of Sickness Absence Trends and progress with the actions, which Barbara Anne Nelson confirmed would all be cross referenced and brought together over time as work progressed; the important lessons learned from the Review, the issue in the Scott Moncrieff Annual Report 2013-14 relating to implementing an Early Departure-Severance Policy, the process of which Karen Jones confirmed had been tightened up by Scottish Government. Barbara Anne Nelson advised that the implementation of this Policy would be considered at the year end.

Action: Barbara Anne Nelson Members noted the update on audit follow up work. 6 FRAUD ACTION PLAN Members received a report from Robin McNaught in respect of the Fraud Action Plan. Robin McNaught summarised the report which provided progress of the action taken to date against measurable tasks. All actions were on plan and being addressed. Members reviewed the Fraud Action Plan which showed progress made and the three actions still outstanding. Robin McNaught would check that the Patient Advocacy Service had been included in Action No 5 – Adopting the Right Strategy – Raising awareness of fraud with contractors.

Action: Robin McNaught Members noted the progress on engagement activities; noted the update on Communication; reviewed the Fraud Action Plan (Appendix 1); and noted the Review of the Top Ten Risks identified from the FRAM (Appendix 2). 7 FRAUD UPDATE Members received a report from Robin McNaught which provided a quarterly summary of alerts received from Counter Fraud Services (CFS) and an update on the Hospital’s Fraud Log. Robin McNaught summarised the update and confirmed that since the last meeting of the Committee, six CFS alerts had been published and all appropriate actions had been taken. There had been three incidents of fraud reported since the last meeting and these were still under investigation. Members discussed a number of issues of the report and noted the strong awareness of fraud across the Hospital.

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Robin McNaught agreed to include dates of incidents in future reports.

Action; Robin McNaught Members noted the alerts circulated by CFS in the last quarter and the update on the fraud allegations. 8 ATTENDANCE MANAGEMENT UPDATE Members received a report from Barbara Anne Nelson which provided an update on the current position with regard to Attendance Management and the actions being implemented to improve performance in this area. It was noted that improvement in staff attendance had been identified as a specific workstream within the Workforce Review which was currently being undertaken. Progress for the period November – December 2015; January – March 2016; and April 2016 – March 2017 was outlined. Members noted that the risks associated with a failure to improve attendance levels are the potential impact on the delivery of services to patients and increased costs in terms of overtime and the potential impact on sustaining the workforce. A number of issues were discussed in relation to the Attendance Management Policy which had been re-drafted, views and feedback on which were being sought from Staff Side; the importance of the Policy being fair, fit for purpose and consistently applied; that staff were being better supported in terms of their return to work; more scrutiny of nursing sickness absence, agreed in partnership, was being undertaken with the intention of rolling out the process across the whole site; that with the increase in HR resources, more support was now available to Line Managers; and that the Action Plan in place to progress the actions required would be useful in taking the process forward. Members noted the Attendance Management Update and the implementation of the agreed Action Plan. 9 POLICY UPDATE Members received a report from Robin McNaught which confirmed that the Hospital had 121 current policies on the Intranet. There were also four new policies, three of these were in the process of being written with the other under consultation. Of the 121 policies, 55 (45%) were currently out of date, however, 38 of these were under review by the appropriate author and five were under consultation. An overview was provided of all policies and their current status. Robin McNaught advised that work was under way to ensure all policies were reviewed on time and alerts were issued to appropriate authors two to three months in advance of the review date to ensure completions in a timely fashion. The Committee welcomed the progress made and noted that some policies were being streamlined and, where possible, others were being merged. The importance of staff consultation on all policies was acknowledged. Members noted the progress of the review of overdue policies with continued close monitoring through 2016. 10 INTERNAL AUDIT PLAN 2015-16 Members received a report from Matt Swann in respect of the Internal Audit Plan 2015-16 Status Update which provided a summary of progress made against the plan.

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Members noted the progress made to date and that due to sickness absence, the Health and Safety Audit would be re-arranged. A number of issues were discussed in relation to the Risk Management – Workshop and Review, the detail of which Matt Swan summarised. The differences between the various Corporate and Local Risks identified were explained and Karen Jones confirmed that only key risks should be classified as corporate and that local risks should be escalated if required. The Risk Management Workshop and Review would be discussed further by Robin McNaught and Matt Swann and further information would be provided at the next meeting.

Action: Robin McNaught/Matt Swann

Members noted the Internal Audit Plan 2015-16 Status Update. 11 COMMUNICATIONS INTERNAL AUDIT REPORT 2015-16 Members received a report from Matt Swann in respect of the Internal Audit Plan 2015-16 which provided a summary of the Board’s communications processes. Members noted that the overall objective of the audit was to consider if communication was consistent with the communications strategy to both internal and external stakeholders and how this compared with good practice. Matt Swann confirmed that a number of areas of good practice were identified under the scope of the Review. Six areas of development were noted, one of which was considered a moderate priority. The Review concluded an assessment of ‘significant assurance with minor improvement opportunities’ reflecting the good practice and the six recommendations identified. Members discussed a number of areas of the Communications Audit in relation to the importance of informing staff of how to source communications; the personal responsibility staff had to keep abreast of communications issued; the value of having a pro-active approach with presentations and the issue of leaflets to the community in order to capture the best possible opportunities with this group; some negative comments noted from the staff survey, which were not reflected in the Audit report; the gaps in internal communications in respect of some areas of the intranet which could on occasion be onerous and had limited resources; that measures should be taken to mitigate the risks and ensure more resilience in this area; the work that was underway on the Communications Strategies in terms of sustainability and quality improvement; that it would have been useful to have had some measurement of the effectiveness of communications included in the report; and the Hospital website, which it was agreed looked dated. Jim Crichton advised of the imminent changes about to come into effect in terms of the Multi-Agency Contingency Plans relating to escape from the Hospital. Members noted the Communications Internal Audit Report 2015-16. 12 PATIENT EXPERIENCE AUDIT REPORT 2015-16 Members received a report from Matt Swann in respect of the Internal Audit Plan 2015-16 which provided a summary of Patient Experience-Feedback. Members noted that the overall objective of the audit was to verify that patient experience was not compromised from non-response to feedback and any issues were appropriately identified and dealt with. Matt Swann confirmed that a number of areas of good practice were identified under the scope of the Review and a small number of development areas were noted, one of which had a moderate priority. The Review concluded an assessment of ‘significant assurance with minor improvement opportunities’ reflecting that there were a number of improvements already planned by the Board. Members discussed a number of areas of the Review in relation to the new arrangements for identifying and tracking formal and informal feedback which was in early transition; and that this

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was currently part of the review of the Business Support Discussions which were currently underway and led by Jim Crichton. Members noted the Patient Experience Internal Audit Report 2015-16 13 PATIENTS’ FUNDS AND VALUABLES AUDIT REPORT 2015-16 Members received a report from Matt Swann in respect of the Internal Audit Plan 2015-16 which provided a summary of Patients’ Funds and Valuables. Members noted that the overall objective of the audit was to assess the processes in place for the management and control of patients’ funds and valuables within the Hospital. In particular, on the recording of patients’ funds and property; and the monitoring of information on funds and valuables. Matt Swann confirmed that an internal audit of Patients’ Funds and Valuables was carried out each year. Three recommendations were raised as a result of the review, one of which was considered a moderate priority. The Review concluded an assessment of ‘significant assurance’ for the 2015-16 internal audit and the areas of good practice were noted. Members discussed a number of issues of the report in relation to photographic records of patients’ belongings being held, however, the security issues with this process were acknowledged; and the importance of patients signing their record of property following the bi-annual checks carried out. Members noted the Patients’ Funds and Valuables Audit Report 2015-16. 14 HUMAN RESOURCES AUDIT REPORT (STAFF TRAINING) 2015-16 (This item was taken after item 10) Members received a report from Matt Swann in respect of the Internal Audit Plan 2015-16 which provided a summary of the Human Resources Audit in respect of Staff Training. Members noted that the objective of the review was to assess the Board’s processes and controls in relation to adhering to policy regarding mandatory training refresher requirements, meeting staff governance standards and making staff aware of the full responsibilities and objectives of their job roles. Matt Swann confirmed that the Review was undertaken during a period of transition within Human Resources and concluded an assessment of ‘partial assurance with improvements required’. Six recommendations were raised as a result of the Review. Members discussed a number of areas of the Review in relation to the outcome of the Review in comparison to the Annual Report of the Corporate Training Plan which had been very positive; the concern about the non-completions of statutory-mandatory training and the possibility of some follow up being discussed at Staff Governance Committee in future; the accountability at Line Manager level and the importance of Lead Directors having visibility of corporate ownership of staff training within their particular Directorate; the issue of resources and the difficulties with releasing staff to undertake training; the key performance management issues evident from the report; the importance of Line Managers having clarity and consistency of the support to be given; and the governance issues within the middle of the organisation that were currently being addressed by Jim Crichton. Members noted the Human Resources Audit Report (Staff Training) 2015-16. Barbara Anne Nelson left the meeting at this point. 15 EXTERNAL AUDIT PLAN 2015-16 Members received a report on the External Audit Plan 2015-16 from Karen Jones. It was noted that the report summarised the work plan for Scott-Moncrieff’s external audit of The State Hospitals Board for Scotland. The core elements of the work would include audit of the Board’s 2015-16

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Annual Accounts, including a review of the governance statement; an interim audit, taking account of the work of internal audit of accounting systems and corporate governance; a review of the internal audit arrangements; and any other work requested by Audit Scotland, for example, completion of local impact returns or targeted follow-up work. Karen Jones advised that she had met with Robin McNaught to discuss the key audit risks. Follow up work would be done on Public Sector Workforce and also on Fraud Initiatives. Reports on this work would follow thereafter. The Committee noted that this was Scott Moncrieff’s final year as External Auditors of the Board, and that new External Auditors would be appointed by Audit Scotland in due course. Members noted the report on the External Audit Plan 2015-16. 16 AUDIT SCOTLAND NATIONAL REPORTS 2015-16 Members received a report from Robin McNaught which advised of the recommendations made following publication of Audit Scotland National Reports issued during 2015-16. These related to Scotland’s Public Sector Workforce Impact Report – June 2015; Issues raised in Audits of Three NHS Boards – October 2015; NHS in Scotland 2015 – October 2015: and Health and Social Care Integration – December 2015. Members noted receipt of these national reports and that actions had been taken where required. 17 OTHER ISSUES: (This item was taken after item 4) Resilience Update: Members received a report from Nicola Watt which provided an annual update of Business Continuity arrangements. Members noted that the term resilience was adopted during the year to represent Business Continuity and Emergency Planning arrangements. The Business Continuity Group subsequently changed their name to the Resilience Committee. Members noted the update provided in respect of local and national resilience arrangements; Policies and Plans; Incidents; Training and Exercising; and National Guidance and Policy. A number of issues were discussed in respect of the Resilience Committee annual action plan; the eHealth Resilience Plan and arrangements in place to mitigate various risks, an update on which the Committee would receive in future; the education required in respect of ownership of responsibilities and actions in relation to resilience requirements; and the reciprocal support with Police Scotland in terms of incidents. Members noted the Resilience Update. Doug Irwin and Nicola Watt left the meeting at this point. 18 ANY OTHER BUSINESS Security Audits: A verbal update of the Security Audits to be undertaken was provided. Members noted that the Hospital had two security audits - an Audit of Practice which was undertaken by the Forensic Network; and an Audit of the Perimeter and Physical Security Measures which was undertaken by an independent advisor.

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The perimeter and physical security audit for 2015-16 was undertaken in May 2015 and was generally positive with no issues of immediate concern. The Committee had agreed previously that the Forensic Network Practice Audit would take place over an 18 month cycle , however, due to some resourcing issues within the Forensic Network, the Audit had yet to be undertaken. The new Forensic Network Manager had been appointed and would take up post in March and the Committee noted that Doug Irwin had been in discussion with the Forensic Network on the arrangements required to undertake the Audit of Practice. The Committee noted, therefore, that the next Forensic Network Audit of Practice would be undertaken outwith the 18 month cycle that the Committee had previously agreed. The Committee would be kept informed of progress.

Action: Doug Irwin/Robin McNaught The Committee noted the delay with the Forensic Network Audit of Practice. 19 DATE AND TIME OF NEXT MEETING The next meeting would take place on Thursday 24 March 2016 at 9.45am in the Boardroom, The State Hospital, Carstairs.

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Date of Meeting: 25 February 2016 Agenda Reference: Item No: 18 Sponsoring Director: Chief Executive Author(s): Chief Executive Title of Report: Chief Executive’s Report 1 BACKGROUND

The items noted below highlight issues in the Hospital, which do not feature on the Board’s formal agenda. 2 GENERAL ISSUES OF NOTE The Chief Executive will provide the Board with a verbal update on the following issues: Update on Director of Nursing and AHP Post Update on workforce plan Feedback from SPSP visit on 4 February Feedback from HAI Inspection on 9 and 10 February PVG Incident and resolution National review of Forensic Mental Health and LD Pathways

3 PATIENT SAFETY UPDATE A brief summary of SPSP activity across the Hospital in the last two months includes: Locally, steady progress is being made across all five of the agreed national workstreams:

• Risk Assessment and Safety Planning (eg Admission Risk Assessment Project) • Restraint, Seclusion and Emergency Sedation (eg Post Incident Debrief Tool) • Leadership and Culture (eg Walkrounds, Surveys and Data Display) • Medicines Management (eg PRN Medication Project and Medicines Reconciliation) • Communication at Points of Transition (eg Handover Document and Pre-weekend

Briefings) Work is being co-ordinated via a multi-disciplinary steering group which is meeting regularly. Data suggests that the programme is beginning to have a positive impact on practice. These are evidenced as follows:

• Psychotropic PRN medication documentation (‘8 rights’). • The reduction of seclusion in Iona. • No reports of use of secure holds in Arran during October, November and December 2015.

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• Initial Risk Assessment completion in less than 4 hours. • Pre / post weekend safety briefing positively evaluated. • Mull Post Physical Intervention debrief pilot. • Medicines reconciliation completion on admission.

The Institute of Healthcare Improvement (IHI) supports the Scottish Government and Healthcare Improvement Scotland in delivering the national Scottish Patient Safety Programme (SPSP). As part of their annual 3 day visit, The State Hospital was chosen to host a half day site visit which took place on Thursday, 4 February 2016. Terry Currie welcomed the visitors and handed over to Jim Crichton who provided an overview of the Hospital’s purpose and environment. Nicola Watt, Risk Management Team Leader highlighted the ongoing workstreams at The State Hospital and the improvement projects supporting these including:

• Analyse Staff Safety Climate Tool feedback and develop action plan. • Improve feedback mechanism from leadership walkrounds. • Quality check / audit of medicines reconciliation on admission. • Pilot feedback to Datix reporter on medication incidents. • Consider how SPSP MH fits within broader QI development at The State Hospital. • Evaluation of post-incident debrief pilot on Mull Hub and roll out.

The visit was very successful and extremely positive comments have been received from IHI, Scottish Government and senior managers within the SPSP programme. 4 HEALTHCARE ASSOCIATED INFECTION (HAI) A brief summary of HAI activity across the Hospital reported to the Infection Control Committee in January 2016 is presented below. The APIC continues to maintain core infection control responsibilities until a replacement is found for the Quality Improvement Facilitator / Hand Hygiene co-ordinator, as a result some of the audits have not taken place as scheduled. Key Points:

• During this period there has been a decline in the number of hand hygiene audits submitted from the Hubs.

• The Hand Hygiene audit tool was amended to reflect a more thorough description of the disciplines across the site in April 2015. Unfortunately with the QIF for HAI post being vacant for since April minimal work has been undertaken to address these learning gaps and thus completing the QI cycle.

• DATIX incidents continue to be monitored by the APIC and Clinical Teams, with no areas identified for concern.

• Cleaning and estates monitoring remain in the green zone with slight variations. • The antimicrobial prescribing is minimal in comparison to other NHS Boards; however the

prescribing that occurs within The State Hospital is being monitored by the antimicrobial pharmacist and the Infection Control Committee.

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Hand Hygiene Audits: Overall Compliance of Audits Submitted/Expected

Audits Submitted

Audits Expected

% of Audits Submitted

Health Centre 3 3 100% Skye Centre 3 3 100% Arran 2 6 33% Iona 9 9 100% Lewis 4 9 45% Mull 4 9 45%

The overall compliance across the site per discipline

The Overall Compliance by Discipline - Hospital

93

7064 64

7883

0

20

40

60

80

100

Nurse Medical AHP Other Psychology Facilities

Discipline

%

Environmental Audits: All audit activity continues to be monitored by the Infection Control Committee. DATIX Incidents (Infection Control): There were a total of 7 incidents for the period under the primary category Infection Control.

• 4 patients complaining of diarrhoea – no obvious cause • 1 incident of exposure to faeces which were deliberate acts by patients • 2 incidents where extraneous items were found in clean laundry

Cleanliness Champions: All Nursing Team Leaders and Senior Charge Nurses are registered on the cleanliness champion program and the progress continues to be monitored by the Learning and Development Team. A further two Nursing Team Leaders completed the programme during this period. Flu Immunisations: In partnership with Occupational Health, the Flu vaccination campaign commenced on 1 November 2015; however staff can still access the vaccination by appointment through Occupational Health. The figures as of 31 December 2015 show a significant decrease in uptake compared to the same period last year, 251 (36.4%) compared to 181 (27.5%) respectively.

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Patient uptake has shown a small increase with 63.2% as opposed to 62.9% accepting flu vaccination. We have 41 patients who fall into the additional “at risk” group, of this 30 (73%) of patients consented to flu vaccination. This is an improvement on 2014/15 uptake of 68% (patient information obtained from Carol Ann Topping). Healthcare Environment Inspection (HEI): The State Hospital received an unannounced visit from the HEI team on 9 and 10 February 2016, our last inspection was 13 November 2013. This was the first inspection of the hospital against the new Healthcare Improvement Scotland Healthcare Associated Infection (HAI) Standards (February 2015). Ahead of the inspection the HEI team reviewed our self assessment which was submitted in June 2015. During the two days the following areas were inspected, with particular attention being paid to the cleanliness of the area and the environmental conditions:

• Health Centre • Gardens and Animal Assisted Therapy • Arran 1 • Arran 2 • Lewis 1 • Mull 2 • Iona 3

Staff in each of these areas were interviewed and observed by the inspection team in relation to infection control knowledge, training and practice. The high level feedback provided on 10 February acknowledged the significant improvements since the last inspection in 2013; however adherence to the uniform policy continues to be an area for concern. The report will be sent to the hospital 16 March for review regarding factual accuracy and will be published 19 April. 5 PATIENT ADMISSION / DISCHARGES JAN 2016 A detailed report on admissions and discharges is provided to the Clinical Governance Committee on a 6 monthly basis. The following table outlines the high level position for January 2016.

MMI LD Total Bed Complement

125 15 140

Staffed Beds (ie those actually available)

117 15 132

Admissions

1 0 1

Discharges / Transfers

2 0 2

Average Bed Occupancy Jan 16

-

-

126 (95.45%)

6 RECOMMENDATION The Board is invited to note the content of the Chief Executive’s report

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a g e n d a 1 apologies for absence and chairperson’s ... papers/2016/tsh board... · board...

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