annual report 2015/16 avon and wiltshire mental health ... · page 4 of 70 avon and wiltshire...

of 70 Avon and Wiltshire Mental Health Partnership NHS Trust

Annual Report 2015/16 Avon and Wiltshire Mental Health Partnership NHS Trust

Contents


Performance Report

Introduction 4

About us 5

Directors Report 8

Remuneration and Staff Report

Remuneration report 20

Working with our staff 25

Corporate Governance Report

Corporate Governance report 29

Appendix 1 41

Disclosures in the Public Interest 45

PALS Praise and Complaints 59

Financial Statements 62

Review of economy, efficiency and effectiveness of the use of resources

Information governance 38

Annual quality report 38

Review of effectiveness 38

Parliamentary Accountability and Audit Report 64

Accounts 2015-16 Appendix 1


Introduction by Hayley Richards, AWP Trust Chief Executive It is common when writing a welcome piece for NHS Trust annual reports to begin: “This has been a challenging year”. The reason for the popularity of that opening line is that, of course, every year is a challenge for the NHS and will continue to be so.

Challenges do not just come from external sources – funding, recruitment, pressures on services – but from within. We challenge ourselves to provide better care, be more compassionate, adopt new practices and do more for less.

This annual report will give you a closer look at the nature of our organisation, what we set as our objectives and ambitions, how well we care for service users, carers and staff, and how well we manage our resources.

Before you turn the page and read on, I would like to make particular mention of some events and people that have helped us deliver against our objectives in the past year.

My immediate predecessor, Iain Tulley, made real improvements to our Trust and how it is perceived. He ensured that our services are clinically led and informed, and that we put the service user at the heart of everything we do. This is something that we shall continue and I am enormously grateful to Iain for his service to AWP and the NHS.

Thanks to the hard work of our caring, compassionate and professional staff at all levels, our Trust is in the process of delivering even more services, including Child and Adolescent Mental Health Services (CAMHS), new prison service mental health services, Learning Disabilities and more. Many of these we are delivering in partnership and we welcome these opportunities for playing a vital part in the larger health community. I am proud that we have made improvements to our services over the year, that we have managed our finances well, and continue to make our Trust a better and fairer place for our staff to work in. Last year we achieved well against our Annual Objectives, and you will read about that at page 7 of the Annual Report. Our performance for quality was above target for 4 of our key areas, with 2 areas marginally below, and 1 area needing much more work.

Every day I hear stories of the way our staff demonstrate their commitment to care and quality. We enjoy sharing those stories with you and hearing of your own experiences. The Friends and Family survey shows increasing numbers of people responding positively to the support they have received.

Where those experiences tell us that we have not delivered services and support of the quality that we would expect for our own families and friends, we take this seriously and endeavour to improve. We understand that you are not merely a name or a piece of data; you are an individual and deserve to be treated with dignity and respect at all times. This is why you will notice a very simple and powerful phrase appearing across our Trust; a phrase that we encourage ourselves to remember at all times:

“You matter, we care”

Chief Executive 25th May 2016

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About us Avon and Wiltshire Mental Health Partnership NHS Trust (the Trust) is a significant provider of mental health services across a core catchment area covering Bath and North East Somerset (BaNES), Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. The Trust also provides specialist services for a wider catchment extending throughout the south west. Delivering services across this wide geography requires the Trust to meet differing health needs across local communities. This geography includes densely populated urban areas, with a large ethnic diversification, and more sparsely populated rural areas with growing aging populations. There are a number of universities, large manufacturing companies and healthcare services across the area, resulting in large transient populations commuting each day, and popular tourist destinations throughout the region.

All these elements combine to make a unique population group accessing the services the Trust provides. In response to this, the Trust offers a locally focussed service in each area, with local business plans aligned to commissioner intentions and strategic development opportunities within the local area.

As a partnership trust, we have important responsibilities to work together at a local level with other public bodies, such as local authorities; the police and the criminal justice system including prisons; and also with the voluntary sector. This is to ensure we provide a joined up service for the communities we serve. Throughout 2015/16, the Trust has continued to work with partner organisations to improve service accessibility, experience and outcome across all and we plan to continue this throughout 2016/17.

This report highlights our strategic direction and the key risks and challenges the Trust is facing currently and in the coming year. It also takes a look back at the key achievements for the Trust during 2015/16.

Our purpose and values

Our purpose is to provide the highest quality mental healthcare that promotes recovery and hope.

We have defined our values as “PRIDE”; Passion, Respect, Integrity, Diversity and Excellence.

Our services

The Trust provides services for people with mental health needs, with needs relating to drug or alcohol dependency and mental health services for people with learning disabilities. We also provide secure mental health services and work with the criminal justice system.

Increasingly, the Trust provides treatment and care in people's own homes and other community settings, reflecting the preferences of our service users. Our community services are supported by high quality inpatient services that provide short term assessment, treatment and care.

The Trust has placed the clinical voice at the centre of its decision making through a devolved, locality focused and clinically led structure designed to bring decision making closer to the local communities we serve.

Each locality, which corresponds to a local authority area, is led by a Clinical Director, supported by a Managing Director and a Head of Quality. This structure is also applied to the service delivery units (SDUs) providing Specialised services and Secure services, which operate over a wider geographical catchment area.

Our Trust’s central support functions add value to our locality management teams, ensuring that Clinical Directors have the support required to be accountable and responsible for our services in each locality.


Services delivered by our Trust in 2015/16 included:

Acute hospital liaison

Ageless adult CMHTs

Attention deficit hyperactivity disorder (ADHD) service

Autism spectrum services

Care home liaison

CAMHS in-patient

Community and forensic learning disability services

Community and in-patient drug and alcohol services

Community and in-patient eating disorder services

Complex interventions teams

Court assessment and referral service (in courts and police custody suites)

Day services – day hospitals, supported day care (inreach), therapy centres, specialist centres for younger people with dementia

Deaf mental health service

Early intervention in psychosis

Electro-convulsive therapy (ECT)

Forensic consultancy, discharge and aftercare services

Forensic intellectual developmental disorder services

Forensic Pathfinder personality disorder service

Inpatient assessment and treatment services for functional and organic illnesses, aged 18 upwards

Inpatient stabilisation and detoxification service with therapeutic programme

In-patient perinatal mental health services for mothers and babies

Intensive services

IAPT

Later life therapies teams

Medium and low secure inpatient services

Memory assessment services

Mental health and substance misuse services in prisons

Mental health liaison, based in acute hospitals

Mother and baby service

Place of Safety service (Bristol)

Primary care liaison

Prison mental health services

Psychiatric intensive care

Chief Executive

Executive Medical Director and Deputy Chief

Executive

Executive Director of Nursing and Quality

Executive Director of Operations

Clinical Director

Bath and North East Somerset*

Head of Quality

Managing Director

Clinical Director

Bristol

Clinical Director

North Somerset

Clinical Director

South Gloucestershire

Clinical Director

Swindon

Clinical Director

Wiltshire

Clinical Director

Secure

Clinical Director

Specialised

Executive Director of Resources

Director of Organisational Development

Director of Corporate Affairs and Company

Secretary


Psychological therapies in primary and secondary care

Recovery services

Rehabilitation inpatient service

Specialist community-based assessment and treatment services for drugs and alcohol, including specialist prescribing and community detoxification

Specialist eating disorder services, inpatient, community and primary care

Specialist input to Secure children’s homes

Specialist mental health learning disability community services

Specialist personality disorder services

Treatment programmes in prisons (12-step prison partnership programme and alcohol-related violence programme)

Veterans mental health services

Our structure Our organisational structure supports our clinically led and locally focused approach to what we do, with the services in every local or service delivery unit led by a Clinical Director. Further detail on how we manage our Trust is included in the Annual Governance Statement at page 29 of this report.

Our strategy Our strategic priorities set the direction for our Trust in achieving our vision. We defined these in 2013/14 and continued to be led by these priorities year on year.

Each year we define the objectives which will support us in the delivery of our priorities. In 2015/16 our strategic objectives were:

2015/16 annual objectives

Priority Aim Objectives

We will deliver the best care

To consistently deliver high quality services that are clinically led,

Maintain CQC registration and achieve full compliance with CQC essential

locally integrated and quality focused.

standards.

Achieve a measureable reduction in avoidable harm.

Improve the physical health of our service user population.

Improve the clinical effectiveness of our services.

To improve service user and carer experience.

To improve medicines management across all Trust localities.

We will support and develop our staff

To develop all members of staff to support improved patient care and promote staff wellbeing.

To address, in full, the 3 most concerning matters in the 2014 staff survey.

To achieve a 10% improvement in response to the question ‘would you recommend your team in AWP as a place to work.

To achieve 100% of substantive staff to receive structured appraisal.

To achieve recommended ‘safer staffing’ levels across all teams.

To reduce staff turnover rate in the Trust by at least 2%.

We will continually improve what we do

To achieve a comprehensive and high functioning acute care pathway across all localities.

To reduce the number of patients placed out of trust area by 50%.

To admit 90% of those needing admission to


beds with home locality.

To reduce overall bed occupancy across the Trust by 5% to enable flow and achievement of objective 2.

To achieve one hour of therapeutic activity per patient in each of our wards every day.

We will use our resources wisely

To improve our efficiency and maximise resources to front line care teams

Achieve 100% of our planned cost improvement schemes.

Reduce our overheads by 3.5% in year.

Achieve our growth income target of £4.2m.

To use our reference costs as a means of improving efficiency and reduce future reference costs by at least 10%.

We will be future focused

To become a sustainable Foundation Trust that meets the needs of it communities and can respond to national and local changes in the health and social care system.

To develop a clear strategy in the light of 5 year forward view.

To operate within our local areas as system leader to the benefit of the wider system.

To make an active contribution to the local, regional and national debate around Mental Health commissioning and delivery.

Achievement of 2015/16 annual objectives

Aim Attainment

1. To consistently deliver high quality services that are clinically led, locally integrated and quality focused.

2. To develop all members of staff to support improved patient care and promote staff wellbeing.

3. To achieve a comprehensive and high functioning acute care pathway across all localities.

4. To improve our efficiency and maximise resources to front line care teams

5. To become a sustainable Foundation Trust that meets the needs of it communities and can respond to national and local changes in the health and social care system.

We have used the below colour codes to indicate the progress against the objective. These are:

Blue Not achieved and objective rolled over to 2015/16

Amber Partially achieved

Green Achieved


Research and development Background

The Trust benefits from good collaboration with three local universities (Bristol, UWE and Bath) and is one of the major national centres for research into suicide prevention. Over recent years, we have worked with our partner universities and NHS trusts in the region to establish Bristol Health Partners - a collaboration of NHS organisations, universities and councils. The Partners mission is to generate significant health gain and improvements in service delivery in Bristol by integrating, promoting and developing Bristol's strengths in health services, research, innovation and education. The Trust has good representation on all Health Integration Teams relevant to mental health including dementia, self-harm, psychosis, psychological therapies and perinatal mental health.

Due to the success of Bristol Health Partners, in 2014, the West of England also secured a Collaboration for Leadership in Applied Health Research (CLAHRC). The purpose of the CLAHRC West is to get the right health research done for a wide geographical area. It undertakes high-quality applied health research, focused on the needs of patients, and supports the translation of research evidence into practice in the NHS.

The Trust is also part of the West England Academic Health Science Network, the objectives of which are to: focus on needs of patients and local people, accelerate the adoption of innovation into practice to improve clinical outcomes and patient experience, build a culture of partnership and collaboration, and make a meaningful contribution to the West of England and UK economy.

The majority of R&D funding is from the National Institute for Health Research Clinical Research Network West of England; this funding is to support the recruitment of service users, carers and staff into national

portfolio (multi-site) studies including randomised controlled trials, observational studies and commercial research.

Strategy

In 2015 we launched our updated R&D Strategy. This was been designed with extensive consultation with service users, clinicians, managers and academics. There are 3 aims of the strategy:

We will conduct and be part of research that makes a difference to the people we serve (including impact and outcomes)

Research will be part of all trust services

We will increase income to the trust through Research and Development

This strategy is closely aligned with the National Institute for Health Research (NIHR) strategy (2012-2017) and the NHS England Research and Development Strategy (2013-2018) as well as local partners strategies and the Trust.

The strategy is closely aligned with the Trusts overarching strategy and will develop an embedded culture of research as core business, including integration into clinical services.

The Trust’s objectives in relation to R&D are:

We will deliver the best care: research is core activity for the Trust, service users like it, and empirical evidence shows that even people in the non-treatment arm of studies receive better care than service as usual. Kingshill Research Centre have achieved excellent Family & Friends results; we are working to use the F&F survey for everyone that takes part in research. Some research we do is offered to people where there is currently no alternative treatment (for example in dementia) meaning patients receive treatment at an earlier phase and receive clinical assessments that save trust services resource that can be focused elsewhere.


Our Clinical Question Answering Service (BEST) has provided quality research evidence to 120 questions relevant to service users, clinicians, service development and research activity in the trust.

We will support and develop our staff: We are committed to developing staff within R&D and in our clinical teams, through initiatives such as Research Link Coordinators, Medical Research Leads and the Specialist Registrar Research Involvement Course (see below). We prioritise requests from internal clinicians who are interested in developing their own research ideas and careers through our Research Capability Funding (RCF) calls. We have conducted our own internal R&D staff survey and developed changes to our ways of working to improve staff support.

We will continually improve what we do: Working with more than 6 Health Integration Teams (through Bristol Health Partners), CLAHRC (including evaluation of system leadership in Mental Health Bristol and Join the Dots). We have continued to foster collaborations with local universities, using RCF to support research focussed on what the trust needs and what our service users tell us is important to them.

We will use our resources wisely: We have internally reviewed our ways of working and internal staff structure to reduce wastage and make our systems more efficient. This includes regular skill mix reviews and multiple minor changes to reduce costs without reducing activity or quality.

We will be future focussed: Everyone Included (our approach to telling people about research) has continued to develop. We have been selected as a site for UK CRIS (an electronic record text mining system to support audit, research and evaluation as well as innovation in service development and change),

working with commercial companies on new technologies and ways of working (Biovici and Otsuka).

Everyone Included

Everyone Included is an innovative Trust-wide approach letting people know about relevant research studies, launched in 2014. Since then we have been embedding this into services, informing service users and implementing processes to support. Everyone Included has been piloted with 5 studies with 5 in progress. We are currently conducting an evaluation of the approach with our service users to ensure we have a mechanism that is what people tell us they want and is continually developed based on their needs.

The original idea for everyone included came directly from service users who wanted easier access to research opportunities and were concerned that busy clinicians may be an obstacle to this or that clinical paternalism may result in them being overlooked for studies. The initial work was based on a series of consultation workshops with service users and has been led more recently by our R&D Service User Involvement Worker. We have service users on the panel which reviews studies for Everyone Included as well as on the R&D Committee which has oversight of all R&D activity.

Medical Research Leads

This initiative was launched to engage medics with research and development. 7 leads have now been appointed and the R&D Department is working closely with these medics to engage with local services and improve service user and staff access to relevant research and new technologies.

Specialist Registrar Research Involvement Course (SpRRIC)

This innovative initiative is the first in the country of its kind and, now in its third year, is proving successful. Due to its success we will be continuing into a 4th year in September 2016. An article on the course is


being redrafted for publication and other regions are interested in adopting the course.

Research Link Coordinators

This initiative was undertaken to engage clinical teams with R&D. The previous pilot proved successful and this year we have continued to develop the programme with 12 Co-ordinators across 10 teams. This programme has been closely evaluated and we are working with clinical teams to embed the programme further in 2016/17.

BEST in Mental Health

BEST in Mental Health is a clinical question and answering service. In 2015/16 it answered over 120 questions including a number submitted by NHS England National Commissioners for Secure Services. Funding for next year is being considered by local GPs via the Avon Primary Care Research Collaborative.

National Institute for Health Research (NIHR)

This financial year AWP has participated in 95 studies; 66 National Institute for Health Research (NIHR) adopted studies, 13 sponsored by commercial companies, and 29 student and non-NIHR research. AWP continues to act as a Participant Identification Centre on NIHR studies with RICE (Research Institute for the Care of the Elderly) and North Bristol NHS Trust.

For our last full year of data (April 2014 to March 2015), comparable figures were: 92 active studies in AWP, 51 NIHR studies, 12 sponsored by commercial companies and 41 student and non-NIHR research. AWP recruited a total of 800 patients into NIHR studies during this period.

The number of patients receiving NHS services provided or sub-contracted by AWP in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was 803 (correct at 24 March 2016), 623 into NIHR studies and a further 180 into student and local clinician led research. In addition, staff

working for AWP have been able to support recruitment of a further 81 people into research studies from other Trusts.

Research and Development: Plans for 2016/17

Implementation of the Trust R&D Strategy for 2015-17.

Develop our Everyone Included approach – improving this with service user feedback and encouraging other NHS organisations to adopt the same approach to ensure we maximise peoples’ opportunities to take part in high quality research.

Innovation with service users, carers and staff to develop and conduct research that makes a difference to the people that we serve.

Kingshill Research Centre in Swindon will continue to develop their approach to commercial research, improve profitability and expansion to secure new contracts.

Focus on dementia studies and commercial research as high priorities for the trust.

We will continue to work in close collaboration with local Universities and Networks to develop research, education and service development activity. In particular we will collaborate with University colleagues to look at negative outcomes in mental health (suicide, self-harm, polypharmacy and the minimisation of harmful effects of interventions and hospitalisation) which are a priority for the Trust.

Performance against key indicators National Indicators

The NHS Trust Development Authority (TDA) monitored our Trust against Monitor’s standards throughout the year. The Trust Board received and reviewed monthly performance reports.


Our performance against national indicators is reported within our Annual Governance Statement on page 29 of this report.

Local Indicators

The Trust also monitored a number of additional indicators as specified in contracts with its commissioners; with performance also reported and reviewed by the Trust Board.

The final results for key indicators in 2015-16 are included below:

Serious Untoward Incidents AWP fully embraced the new Serious Untoward Incident Framework published by NHS England from 1 April 2015 and subsequently reported a total of 132 serious incidents to its commissioners. Although recognised as a strong reporter of incidents by its commissioners, AWP recognised improvements could be made in order to produce quality root cause analysis investigations within required timescales and we have undertaken a significant piece of quality improvement work to correct that position. This included the establishment of a centralised investigations team.

The Trust worked hard to include service users and/or their families in investigations wherever possible, with a real emphasis of effectively discharging our Duty of Candour responsibilities. Learning from investigations is captured centrally and cascaded throughout the organisation using Safety Matters Bulletins and Red Top Alerts to ensure we are constantly learning. The Mazaars Report was reviewed and informed changes to practice to ensure we met the best practice requirements of incident reporting.

The categories of serious untoward incidents reported is shown in the table overleaf:

Performance against local Commissioner indicators

Indicator Target Result

Service users in employment 10% 12%

Service users in settled accommodation

70% 67%

4 hour wait for crisis assessment 95% 98%

Referral to assessment 95% 89%

Referral to treatment (excluding IAPT and EI)

95% 96%

IAPT – access rates 15% 16%

Supervision rate 85% 84.8%

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Employees Equal opportunities

We are an equal opportunities employer and abide by the Equality Act 2010, which consolidated, strengthened and clarified existing anti-discrimination legislation. As a public sector body we are under an additional duty to eliminate unlawful discrimination, advance equality of opportunity and foster/encourage good relations between different groups. The Trust is committed to promoting equality, diversity and human rights for our staff. We recognise that everyone is different, and want to ensure our employment practices respect, promote and celebrate these differences. Our Workforce Diversity and Equal Opportunities Policy framework provides clarity around the equalities legislation that applies to the Trust as a public body, sets out roles and responsibilities and standards of behaviour that the workforce must adhere to in this regard. This policy underpins the application of other organisational policies which outline how the Trust will respond to allegations of inappropriate behaviour linked to equality and diversity issues, such as the Bullying, Harassment and Dignity at Work Policy.

Our staff

The Trust protects people from unlawful discrimination, victimisation, bullying or harassment on the grounds of race, sex, gender reassignment, religion or spiritual beliefs, disability, mental health needs, age, marital status, domestic circumstances, social class, sexual orientation, ex-offender status, political allegiance or trades union membership.

At the time of producing this report the gender distribution of our staff was:

Gender distribution

Staff group Female Male Total

Directors 6 7 13

Other senior

managers 181 83 264

Other employees 2644 966 3610

Total headcount 2831 1056 3887

Headcounts given above exclude locums, honorary contracts and bank staff. Directors include voting members of the Board. Other senior managers are those staff in bands eight and nine and senior medical staff. Other employees include all other staff on Agenda for Charge pay scales and staff who have been transferred under the Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE) on other pay scales. The Trust acknowledges and respects the fundamental human right of every person not to be discriminated against on the grounds of perceived difference. Direct and/or indirect discrimination, harassment or victimisation will not be tolerated within the workplace, or in the way services are delivered or functions and duties carried out.


We welcome applications from disabled

people, who are an under represented

group in the workforce of the NHS. We will

make reasonable adjustments to ensure that

disabled workers are not disadvantaged

when doing their jobs.

Our Learning and

Development policy

This policy describes the objectives that

underpin learning and development within

the Trust, the processes and expectations

through which the annual learning and

development plan for the Trust is developed

and the mechanisms; expectations and

monitoring procedures to ensure there is a

fair and equitable access to training to

ensure all staff are developed to meet the

expectations of their job role and Trust

objectives.

The key changes to this policy are:-

The policy reinforces the various

roles and responsibilities of the

variety of stakeholders;

Specific requirements of staff with

disabilities or who require access to

training in alternative formats are

expressly and proatively taken into

account;

The policy now introduces a

structure to support improved

compliances and efficient use of

resources;

The policy updated roles,

terminology and governance

structure;

Accountability to approve changes to

statutory/mandatory training.

This policy will provide clarity regarding

organisational, role and individual

responsibility and all staff should be aware.

Further work will now take place in respect

of formalising a Career Framework for AWP,

which will inform and support workforce

based priorities which include:

Apprenticeships

Leadership Development

Access to registered training

Clarity on core essential skill

development.

Through the Trust's equality monitoring

processes, there will be an analysis of access

to training and CPD across protected

characteristics on an annual basis.

Appropriate actions will be taken to ensure

that equality of opportunity is promoted and

implemented as part of the Trust's Talent

Management work.

Engaging with our communities

Surveys

Our results improved for both the 2015 national Community Mental Health Survey and the Inpatient Survey compared to last year. Scores for the majority of questions were higher than in 2014. We had the top score in the country for people in the community being given information about medication in a way that was easy to understand and were much improved for people knowing who to contact in a crisis. There were significant improvements for people who had been inpatients saying that nurses listened carefully to them and that they felt safe on the ward.


Over 10,000 Friends and Family Test responses were received this year. 89% said that they would recommend our services. Participation has increased steadily since April 2013, with over 23,000 responses to date. The majority of comments are positive, telling us that our staff are hard-working, caring and professional. Comments are reviewed locally each month, and, where concerns are raised, we are quick to respond and make improvements.

Further information is available in the Trust Quality Account 2015-16.

Volunteering

We really appreciate the time and skills our volunteers contribute, which help to improve the service user experience. Arts and crafts, music and helping out with service user surveys are just some of the roles volunteers undertake in the Trust. We have over 150 volunteers and are always developing new roles in response to staff feedback and to make best use of the many skills and qualities of our new volunteers. In 2016, we aim to develop more community volunteering opportunities. We make sure that they have the training they need to be safe and confident in their roles and local staff offer regular supervision.

We work closely with a number of other organisations. Pets As Therapy (PAT) dogs (with their owners!) regularly visit a number of wards and always receive a warm welcome. Bristol University students continue to offer lively activities for service users at our Callington Road site in Bristol on Sunday evenings in term time. We also work with Second Step and the Royal Voluntary Service.

In October, at the annual awards ceremony, the winning volunteer was Justin Brown. He has Autistic Spectrum Disorder (ASD) and has volunteered with BASS autism support service for adults in Bristol since it was established and made a significant contribution, always making people feel welcome and setting up a service user

steering group. Worthy runners up were: Dylan Channon, for his volunteering on Juniper Ward in Weston and Chris Pollack, who volunteers every week at Hillview Lodge in Bath.

Family, Friends’ and Carers’ Charter

The charter was developed by carers and staff and signed up to by the Trust Board in April 2014. The Charter contains 11 standards. During 2015 a group of carers in the BaNES LDU has developed an explanation leaflet of the standards. This has now been given trust-wide approval and will be used in 2016 to continue to help implement and embed these standards.

Healthwatch

The six local Healthwatch in the AWP area comment on our Quality Account and take part in the annual PLACE visits to wards (Patient Led Assessments of the Care Environment). Healthwatch Bristol undertook ‘Enter and View visits’ to a number of local wards in the autumn. We welcomed the fresh perspective these visits provided and are putting in place a number of improvements as a result of the feedback.

A Joint Working Agreement is in place with Healthwatch and the Healthwatch Stakeholder Group meets regularly. There is a Trust wide Healthwatch lead and each locality has two staff Healthwatch leads who link with Healthwatch in their area to share information about our services and listen and respond to public feedback, in order to better understand local people’s views about our services.

Carer Involvement

Involvement Coordinators continue to recruit carers in their Localities to ensure carer engagement in a wide range of projects and carer representation at a Trust-wide level in the Carers’ Forum. Acknowledging and valuing carers’ expertise and first-hand knowledge of supporting someone with mental health problems is an integral part of ensuring high quality and responsive services.


Trust-wide Carers’ Forum

This group is made up of Carers, Involvement Coordinators and third sector partner organisations. It had been meeting on a quarterly basis, since 2002, providing an opportunity to oversee, scrutinise and monitor the work being done to improve partnership with carers and carer organisations.

However, since January 2016 the Forum has been restructured. It now meets every six weeks and the Director of Nursing and Quality is a member. He is in a position to take carer issues raised by the carer representatives, from the Local Delivery Units (LDUs), to the Board for action. Decisions and actions that the Board feel need to be taken are then cascaded back to Forum members. If appropriate work groups of carers and staff are set up to oversee actions or processes that need to be completed to resolve the issues.

Network of Champions

It has been important to continue to ensure that there are Carer Leads across each of the 8 Local Delivery Units. They are vital in supporting the Carer Champions in each of the clinical teams. Their leadership maintains the support and promotion of learning and dissemination of good practice. It is the Carer Leads who keep the momentum if staff in teams change and Carer Campions change. The work to embed the Triangle of Care in the last two years has in no small part been the product of having these senior staff in place. They and the Carer Champions are vital to continue to deliver the Trust’s carer agenda.

Triangle of Care

In 2014 AWP became a member of the Triangle of Care national scheme. Initially the Inpatient, Intensive and Rehabilitation services made self-assessments against the six standards in the Triangle of Care which were submitted for national scrutiny. As a result AWP were awarded one star. By May 2015 all the Community Teams had

completed their self-assessments for Phase Two and gained a second star. Participation in the scheme demonstrates AWP’s commitment to working in partnership with family, friends and carers of people using our services. Action plans resulting from the Triangle of Care self- assessments are actively monitored through local governance meetings and at a Trust-wide level through the Carers’ Forum. In this way AWP ensures on-going improvement to partnership working and embedding the standards in the Triangle of Care.

Communicating via Social Media

We also use social media platforms, including Facebook and Twitter to both send out information and messages, and encourage feedback from partners, public and communities. With a growing and very active social media presence, we will continue to use all appropriate methods of communication to reach out to as many people as possible.

Foundation Trust membership Our Foundation Trust Membership Strategy aims to increase participation of our members in the business of the Trust. Recognising the value of working in partnership, our aim is to weave together the strands of work delivered by this strategy with involvement and engagement strategies, to ensure that we work in collaboration with our local communities.

With an active membership of around 16,000 people, including service users and carers, staff and public members, our members provide a valuable arena for any involvement, engagement and inclusion activities.


Sustainability Report Over the next 5 years we intend to further reduce our Carbon Production by a further 18%

This is a difficult target but will be achieved through the following types of actions:

Continue to reduce the amount of space the Trust occupies and reduce the amount of poorly insulated older buildings yet retain contacts with the communities we serve;

Continuing to manage our remaining estate in a good condition including up grading boilers etc. and other plant with more efficient equipment when replacement is due;

Increase the utilisation of our estate to make it work in a more environmentally efficient way i.e. longer opening hours but reduced heating load due to better system management;

Further reduce travelling to deliver Trust activity via improved teleconferencing etc.;

Engage more effectively with staff on recycling.

Directors’ Report


Statement of disclosure Declaration to the effect that, in the case of each of the persons who are the directors/members at the time the report is approved:

so far as the director/member is aware, there is no relevant audit information of which the Trust’s auditor is unaware

he/she has taken all the steps that he ought to have taken as a director/member in order to make himself aware of any relevant audit information and to establish that the Trust’s auditor is aware of that information

By order of the Board

Chief Executive

25th May 2016

Remuneration Report


Remuneration and pension benefits of Senior Managers

Salary Expense

payments¹

Performance

pay and

bonuses

Long term

performance

pay and

bonuses

All pension-

related

benefits

TOTAL Salary Expense

payments¹

Performance

pay and

bonuses

Long term

performance

pay and

bonuses

All pension-

related

benefits

TOTAL

(bands of

£5000)

(taxable)

total to

nearest

£100

(bands of

£5,000)

(bands of

£5,000)

(bands of

£2,500)

(bands of

£5,000)

(bands of

£5000)

(taxable)

total to

nearest

£100

(bands of

£5,000)

(bands of

£5,000)

(bands of

£2,500)

(bands of

£5,000)

£000 £00 £000 £000 £000 £000 £000 £00 £000 £000 £000 £000

Anthony Gallagher - Chair 25-30 0 0-5 0-5 0-2.5 25-30 20-25 0 0-5 0-5 0-2.5 20-25

Iain Tulley - Chief Executive (Until 31st January 2016) 135-140 65 0-5 0-5 0-2.5 140-145 160-165 67 0-5 0-5 57.5-60 230-235

Hayley Richards - Medical Director (until 31st Jan 2016). From 1st Feb Acting Chief Executive 145-150 36 0-5 0-5 145-147.5 295-300 145-150 36 0-5 0-5 0 145-150

Sue Hall - Director of Resources 125-130 36 0-5 0-5 87.5-90 215-220 110-115 36 0-5 0-5 97.5-100 215-220

Andrew Dean - Director of Nursing (from 16th March 2015) 125-130 36 0-5 0-5 0-2.5 125-130 5-10 2 0-5 0-5 0 5-10

Alan Metherall - Acting Director of Nursing (until 15th March 2015) 90-95 30 0-5 0-5 0-2.5 95-100

Kristin Dominy - Director of Operations (Until 21st August 2015) 40-45 14 0-5 0-5 325-327.5 370-375 90-95 36 0-5 0-5 17.5-20 115-120

Emma Roberts - Director of Corporate Affairs and Company Secretary 75-80 35 0-5 0-5 10-12.5 90-95 80-85 36 0-5 0-5 30-32.5 115-120

Rachel Clark - Director of Organisational Development 85-90 36 0-5 0-5 15-17.5 100-105 80-85 36 0-5 0-5 77.5-80 165-170

Matthew Page - Acting Director of Operations (from 22nd June 2015) 70-75 28 0-5 0-5 135-137.5 210-215

Daniel Meron - Acting Medical Director (until 31st Jan 2016) 110-115 0 0-5 0-5 117.5-120 230-235

Timothy Williams - Acting Medical Director (from 4th Jan 2016) 25-30 0 0-5 0-5 57.5-60 85-90

Non Executive Directors

Anthony McNiff (Until 31st Dec 2015) 0-5 0 0-5 0-5 0-2.5 5-10 5-10 0 0-5 0-5 0-2.5 5-10

Susan Thompson 5-10 0 0-5 0-5 0-2.5 5-10 5-10 0 0-5 0-5 0-2.5 5-10

Barry Dennington (from 17th August 2014) 5-10 0 0-5 0-5 0-2.5 5-10 0-5 0 0-5 0-5 0-2.5 5-10

Graham Coxell (Associate) (Until 9th Sept 2015) 0-5 0 0-5 0-5 0-2.5 0-5 0-5 0 0-5 0-5 0-2.5 0-5

Ruth Brunt 5-10 0 0-5 0-5 0-2.5 5-10 5-10 0 0-5 0-5 0-2.5 5-10

Peaches Golding 5-10 0 0-5 0-5 0-2.5 5-10 5-10 0 0-5 0-5 0-2.5 0-5

Lee O'Bryan (Until 14th Oct 2015) 0-5 0 0-5 0-5 0-2.5 0-5 5-10 0 0-5 0-5 0-2.5 5-10

Ernest Messer (From 1st Feb 2016) 0-5 0 0-5 0-5 0-2.5 0-5

Charlotte Moar (From 1st Feb 2016) 0-5 0 0-5 0-5 0-2.5 0-5

Mark Outhwaite (From 1st Feb 2016) 0-5 0 0-5 0-5 0-2.5 0-5

Notes:

1. The expense payments relate to car allowances

2 Hayley Richards - Acting Chief Executive from 1st February 2016

All of the above Directors were in post for the 12 month period to 31st March 2016 except where indicated.

No annual performance or long term performance related bonuses were paid during the period.

No senior manager in the current or previous financial year has received a payment for loss of office.

Salary amounts include all salary paid and payable to the Directors by the Trust; this may include payments in arrears made during the year.

Band of Highest Paid Directors Total Annualised Remuneration (£'000)

Median Total Remuneration

Ratio 6.7

170-175

25,755

Name and Title

2015-16

170-175

22,277

7.7

2014-15


Pension Benefits

Real increase in

pension at

pension age

Real increase in

pension lump

sum at pension

age

Total accrued

pension at age

60 at 31 March

2016

Lump sum at

age 60 related

to accrued

pension at 31

March 2016

Cash Equivalent

Transfer Value

at 1 April 2015

Real Increase in

Cash Equivalent

Transfer Value

Cash Equivalent

Transfer Value

at 31 March

2016

Employers

Contribution to

Stakeholder

Pension

(bands of

£2500)

£000

(bands of

£2500)

£000

(bands of

£5000)

£000

(bands of

£5000)

£000

£000 £000 £000 £000

1-2.5 1-2.5 60-65 180-185 1,135 18 1,170 0

5-7.5 20-22.5 55-60 170-175 962 155 1,128 0

2.5-5 7.5-10 30-35 100-105 486 67 559 0

* * * * * * * 10

12.5-15 42.5-45 55-60 120-125 745 108 1,031 0

0 0 5-10 0 51 8 59 0

12.5-15 47.5-50 15-20 45-50 248 14 265 0

Matthew Page - Acting Director of Operations (from 22nd June 2015)1 15-17.5 52.5-55 15-20 50-55 161 60 241 0

Daniel Meron - Acting Medical Director (until 31st Jan 2016)1 5-7.5 15-17.5 25-30 85-90 431 101 557 0

Timothy Williams - Acting Medical Director (from 4th Jan 2016)10-2.5 0 25-30 85-90 421 4 443 0

As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.

Cash Equivalent Transfer Values

Real Increase in CETV

Notes:

1. Relates to Part year employment

2. Employee is member of NEST scheme of negligible accrued benefit

All the figures in the above table, together with the pay multiples on Page 23 have been subjected to external audit

Name and title

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any

contingent spouse’s (or other allowable beneficiary's) pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when

the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the

pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual

has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are

calculated in accordance with the Occupational Pension Schemes (Transfer Values) Regulations 2008.

This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, and contributions paid by the employee (including the value of any benefits transferred from

another scheme or arrangement).

Hayley Richards - Medical Director

Iain Tulley - Chief Executive

Sue Hall - Director of Resources

Andrew Dean - Director of Nursing (from 16th March 2015)¹,²

Kristin Dominy - Director of Operations

Emma Roberts - Director of Corporate Affairs and Company Secretary

Rachel Clark - Director of Organisational Development


Staff Numbers 2015-16 2014-15

Permanently

Total Employed Other Total

Number Number Number Number

Average Staff Numbers

Medical and dental 250 228 22 210

Ambulance staff 0 0 0 0

Administration and estates 561 472 89 727

Healthcare assistants and other support staff 1033 518 515 548

Nursing, midwifery and health visiting staff 1750 1615 135 1746

Scientific, therapeutic and technical staff 411 402 9 656

Social Care Staff 0 0 0 0

Healthcare Science Staff 0 0 0 0

Other 0 0 0 0

TOTAL 4005 3235 770 3887


Remuneration Committee Director’s salaries (excluding Non-Executive Directors) are determined by the Trusts Remuneration Committee, the membership consisting of the Chairman and all the Non-Executive Directors. The policy of the committee is to reward Executive Directors fairly, individually and collectively to recruit and retain high quality people, ensuring a clear link between pay increases and Trust performance. The purpose of the Committee is to consider the remuneration and terms of service, including any performance related elements and the provision of other benefits, for executive members of the Trust Board.

During the period there were no compensation payments made to former senior managers, nor any amounts payable to third parties for the services of a senior manager with Board level authority.

Independence of Non-Executive Directors is established in accordance with good governance principles, defined for the NHS within the Healthy NHS Board: principles for good governance and the NHS Foundation Trust Code of Governance. Interests of Non-Executive Directors are reported on page 54

Signed


Exit packages and severance payments The Trust did not pay any exit packages to its directors during the 2015/16 financial year. Exit packages for all other Trust staff can be found in note 7.4 in the accounts.

Directors expenses

Expenses paid to Directors from 1 April 2014 to 31 March 2016

Directors 2015-16 2014-15

Number of paid Directors in office

11 9

Number of Directors receiving expenses

8 7

Total sum of expenses paid to Directors

£28,600 £27,900

Hutton review of fair pay – pay multiple Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median remuneration of the organisation’s workforce. In this context the median is defined as the total remuneration of the staff member who lies in the middle of the linear distribution of staff, excluding the highest paid director. The median is based on the annualised, full time equivalent remuneration for the year excluding employers’ costs.

The banded remuneration of the highest paid director of the Trust in the financial year 2015/16 was £170k to £175k (2014/15 £170k to 175k). This was 7.7 times (2014/15 6.7 times) the median remuneration of the workforce, which was £22,277 (2014/15 £25,755).

Total remuneration includes salary, non-consolidated performance-related pay if applicable and benefits–in-kind. It does not include severance payments, employer pension contributions or the cash equivalent transfer value of pensions. The highest paid director’s salary increase was the most significant factor affecting the ratio.


Better Payment Practice Code and additional pension liabilities A statement describing the better payment practice code, any other policy adopted on payment of suppliers, performance achieved and the number and average additional pension liabilities for individuals who retired early on ill-health grounds during the year can be found in the note 8.3 to the accounts.

External Auditor’s remuneration The remuneration paid to the External Auditor in respect of the audit of the accounts for 2015/16 was approximately £67,000 (Trust and Charitable Fund) and £12,000 (Quality Accounts) inclusive of VAT.

Off-payroll engagements Reporting of off-payroll engagements earning

more than £220 per day

For all off-payroll engagements as of 31 March 2016, for more than £220 per day and that last longer than six months

Number of existing engagements as of 31 March 2015

5

Of which, the number that have existed:

For less than one year at the time of reporting

5

For between one and two years at the time of reporting

0

For between two and three years at the time of reporting

0

For between three and four years at the time of reporting

0

For four or more years at the time of reporting

0

For all new off-payroll engagements between 1 April 2015 and 31 March 2016, for more than £220 per day and that last longer than six months

Number of new engagements, or those that reached six months in duration, between 1 April 2014 and 31 March 2015

2

Number of new engagements which include contractual clauses giving the Trust the right to request assurance in relation to income tax and National Insurance obligations

2

Number for which assurance has been requested

2

Of which:

Assurance has been received 2

Assurance has not been received 0

Engagements terminated as a result of assurance not being received

0

Off-payroll engagements of board members with significant financial responsibility between 1st

April 2015 and 31st March 2016

Off-payroll engagements of board members

Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the year

0

Number of individuals that have been deemed “board members, and/or senior officers with significant financial responsibility” during the financial year. This figure includes both off-payroll and on-payroll engagements.

0

Working with our staff


NHS National Staff Survey results The Trust values the hard work of our staff and their dedication to providing high quality mental health care that promotes recovery and hope. We have committed to supporting and developing our staff as a strategic priority.

We undertake regular ‘temperature checks’ on staff experience and wellbeing. Throughout the year every member of staff is invited to complete the Staff Friends and Family Test in addition to the NHS Staff Survey.

Survey results are analysed by each of our Localities and from a whole organisation perspective to provide a Trust wide picture. Results are used to develop and refine plans to improve staff experience of working at the Trust.

The Trust wide results of the 2015 Annual Staff Survey are reported below.

Staff Survey Response Rate

2014

Trust National average

51% (1790 staff) 42%

2015

49.9% (1750 staff) 46.1%

Comparison with other Mental Health Trusts

Year (No of key findings) 2014 (29) 2015 (32)

Above national average 10% (3) 9% (3)

On a par with national average

10% (3) 47% (15)

Below national average 80% (23) 44% (14)

We are pleased with the positive response rate and value the feedback received from staff.

Survey results have improved compared with 2014. We are pleased that the actions of our Localities, HR and Organisational

Development Teams are making a difference.

In the past year we have maintained a focus on staff engagement through leadership and team development, staff health and wellbeing; and staff recognition and benefits schemes.

Staff engagement has been shown to link with care quality and safety and we are pleased that our staff engagement score has improved.

Year 2014 2015

AWP Staff Engagement Score

3.6 3.68

Average MH Trust Staff Engagement Score

3.72 3.75

Highest Five Ranking Key Finding Scores

2015

Highest 5 Ranking Scores

Trust National average for mental health/ learning disabilities

Percentage of staff reporting errors, near misses or incidents witnessed in the

last month

93% 91%

Percentage of staff appraised in last 12 months

91% 89%

Percentage of staff experiencing physical violence from patients, relatives or the

public in last 12 months

19% 21%

Percentage of staff feeling pressure in the last 3 months to attend work when

feeling unwell

54% 55%

Percentage of staff / colleagues reporting most recent experience of violence

85% 84%


Lowest Five Ranking Key Finding Scores

2015

Lowest 5 Ranking Scores

Trust National average for mental health / learning disabilities

Quality of non-mandatory training, learning or development

3.91 4.01

Percentage of staff agreeing that their role makes a difference to patients / service

users

85% 89%

Quality of appraisals 2.97 3.11

Percentage of staff / colleagues reporting most recent experience of harassment,

bullying or abuse

39% 49%

Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

36% 32%

We remain committed to improving staff experience and wellbeing and will build on the positive improvements in the coming year.

Sickness absence Our Trust Strategic Workforce Group (previously Employee Strategy and Engagement Committee) reviewed sickness absence rates on a regular basis through the year. This was in addition to the fortnightly review of the sickness levels with all members of the senior leadership teams through the Quality Huddle.

The Trust agreed a sickness absence target for 2015/16 was 4.6% averaged over the previous 12 months. In April 2015 sickness absence levels were 4.55%. For 2015/16 the rolling sickness figure was 4.51%.

Total days lost to sickness

2014-15 and 2015-16

2015-16 2014-15

Number Number

Total Days Lost¹ 33,283 33,566

Total Staff Years

3,255 3,354

Average working Days Lost 10.2 10.19

¹ The days lost refer to calendar days.

² There is a difference between the staff years and permanently employed number (3,235) due to the latter being the average staff employed over the year whilst the former is the number of staff in post at 31st March 2016. The years relate to calendar year.

The table above demonstrates the number of days lost to absence during the year, the total staff years lost and the average working days lost per member of staff due to staff sickness.

While the Trust was pleased to have achieved its absence target it recognises that absence continues to impact on service user care and staff wellbeing. The Trust will continue with its efforts to support staff to maintain and improve their health and wellbeing.

The Health and Wellbeing Programme delivered a range of health and wellbeing resources and programmes to support staff to improve and maintain both their physical and mental wellbeing through the year.

The Trust continued to make flu vaccinations available to all staff across the Trust; 44.4% of staff received vaccinations. This is a small increase on the uptake in 2014 (44.1%).

The Occupational Health service provider has supported the Trust with a number of wellbeing initiatives during the year. Regular reviews with the Account Manager and the Area Director continues to result in a more proactive approach to ensure staff and managers receive timely health advice.


Our ambition Our ambition is to be the best Mental Health Employer in England and as such we take feedback from staff seriously. Our focus for the coming year is in three main areas.

Dignity at Work

Last year we commissioned an independent review of staff reported bullying and harassment and as a result introduced a bullying and harassment hotline to provide staff with confidential support to discuss concerns, receive advice about how to take forward their concerns and offer support. In addition, we have raised the profile of bullying and harassment with a campaign to encourage staff to report concerns. Staff Survey results indicate that this remains an area of concern and we have more to do. We will take the following actions.

Establish Staff Experience Groups: We will establish local staff experience groups to discuss staff health, wellbeing and dignity at work and engage staff in finding solutions that will improve local staff experience. Members of Local Staff Experience Groups will join a Trust wide Staff Experience Group chaired by the Chief Executive. The aim of these groups is for staff to raise concerns in a timely way and respond swiftly.

Staff Compact: Building on our Trust values, we will work with staff to describe clear standards of behaviour expected by every member of staff. We will use this as a means of staff holding one another and leaders to account for their impact at work.

Management and Leadership Development: We will build on our existing leadership programmes for managers and advocate an inclusive leadership style that values diversity of opinion and thought and is welcoming of new ideas. We will offer training in managing difficult conversations and offer 360 feedback to managers to understand their personal impact.

Diversity Network: We will work with staff from different backgrounds to understand

their experience at work and take action to address unconscious bias and promote wellbeing.

Culture of Care Barometer: We will introduce a culture of care barometer to measure staff confidence to report areas of concern, support received from local managers and whether staff see senior leaders living Trust values. The Culture of Care Barometer has been piloted and will be rolled out Trust-wide in the coming year.

Quality of Supervision and Appraisal

We are confident that our staff receive regular supervision and appraisal. We believe they are fundamental to staff feeling valued, supported and engaged at work and ensure that staff members are clear about their role and priorities and supported to develop.

To improve the quality of the supervision and appraisal experience we offer Supervision and Appraisal Training to managers. The coming year will see developments in the appraisal process to increase the visibility of learning and development opportunities and the development of career frameworks for all staff groups.

The Career Framework will describe the skills, competencies and training needs of different roles; supporting members of staff to understand how they can develop relevant skills to grow professionally.

We will continue to offer development for all members of staff and apprenticeships will remain a key focus in the coming year.

Health and Wellbeing

We have an active health and wellbeing programme and work closely with our occupational health provider to support staff wellbeing. Financial benefits are offered through a range of salary sacrifice schemes that have proved popular over the past year. Health and wellbeing is embedded in our appraisal approach.


Our priorities in the coming year are:

Staff Recognition: We continue to celebrate Team of the Month, long service and our staff awards. This will be complemented by our AWProud campaign to say thank you every day to staff for their great work. Staff can say thank you to other members of staff by means of e-cards and certificates. The launch of AWPeople, a staff newspaper will recognise the great work of our teams around the organisation.

Physical and Mental wellbeing: We will facilitate staff physical and mental wellbeing well-being through campaigns, information, our caseload management tool, training programmes and developing managers to support wellbeing. Wellbeing will be a priority for our Staff Experience Groups.

Team Health-check: We will work with team managers to develop a team health-check that makes sure the wellbeing of individual and the team as a whole is regularly reviewed.

Corporate Governance Report


Annual Governance Statement 2015/16

Scope of Responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of Avon and Wiltshire Mental Health Partnership NHS Trust’s (‘the Trust’s’) policies, aims and objectives, whilst safeguarding the public funds and Trust assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the organisation is administered prudently and economically and that resources are applied efficiently and effectively.

I also acknowledge my responsibilities as set out in the Accountable Officer memorandum demonstrating an understanding of propriety and accountability issues. As the Chief Executive Officer I am accountable to the Board and Chairman. I am also accountable, along with the Board, to the Secretary of State via the NHS Trust Development Authority.

The Purpose of the System of Internal Control The system of internal control is designed to manage risk to an acceptable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of the effectiveness of our controls. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of the Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage those risks efficiently, effectively and economically. The system of internal control has remained in place in the Trust for

the year ended 31 March 2016 and up to the date of approval of the annual report and accounts.

I confirm that arrangements in place for the discharge of our statutory duties is have been checked for irregularities and to the best of my knowledge we remain compliant with those duties as set out in this statement.

How We Are Managed Avon and Wiltshire Mental Health Partnership NHS Trust has an annual turnover of £197.4m and a workforce of 3,235 FTE substantive staff serving a population of over 1.8 million people.

The Trust is divided into six locality directorates and two functional directorates which form the structure of the Trust and its internal control framework. The Trust has identified three overarching areas of Executive responsibility as follows.

Delivery Executive Operations Directorate

Services are delivered over six locality delivery units (LDUs) and two service delivery units (SDUs) covering all of the Trust’s services. This is our Operations directorate, led by the Executive Director of Operations, supported by a ‘triumvirate’ management team in each LDU and SDU made up of a Clinical Director, Managing Director and Director of Quality.

The Operations directorate leads the delivery of all Trust services.

Clinical Executive Nursing and Quality Directorate

The Nursing and Quality directorate sets the standards for the quality of our care.

The Executive Director of Nursing and Quality oversees patient safety, health and safety, clinical and quality governance, patient advice and complaints, safeguarding,


service user and carer engagement and mental health legislation compliance.

Medical Directorate

Led by the Executive Medical Director, the Medical directorate leads the Trust’s Clinical Strategy, medical staffing, setting standards, ensuring compliance with professional standards and supporting medical education, and providing Pharmacy services Trust-wide.

The eight Clinical Directors are accountable for ensuring that governance arrangements within their LDU or SDU are robust, and are held to account for so doing by the Executive Medical Director.

Business Executive Resources Directorate

The Resources directorate, led by the Executive Director of Resources, includes the finance, human resources, estates, business intelligence, strategy and business development, IM&T and contracts and procurement functions of the Trust.

Corporate Affairs Directorate

The Director of Corporate Affairs and Company Secretary leads the Corporate Affairs directorate which manages Trust communications, corporate governance and risk management, legal services, information governance, compliance and inclusion, including management of the Trust’s membership which is around 16,000 members.

Organisational Development Directorate

Supporting the Trust’s workforce, our Director of Organisational Development leads the Organisational Development directorate to provide a broad programme of organisational development, focused staff engagement and training and development opportunities to our large and diverse staff groups.

This structure is supported by effective and robust governance systems.

In addition to the internal governance and control framework, to fulfil our objectives, the Trust requires effective partnership working across the wider health economy in each of the six commissioning areas the Trust covers.

Avon and Wiltshire Mental Health Partnership NHS Trust has developed a clear clinically-led approach to delivering services with devolved management to enable locally-focused services within a robust, self-regulated structure.

Quality Governance Building on the work in 2014/15 to implement improvements in quality governance highlighted through the Pilot CQC Hospital Inspection process, the Trust continued to develop its approach to identifying and responding to quality issues throughout the year.

This section summarises the Trust’s Quality Governance and provides assurance about how we prepare and publish the Annual Quality Account, clinical audit, never events and SUIs.

Quality of services remains at the heart of all that we do in AWP and our focus on quality of delivery is a priority. Our objective remains is to provide high quality services that are clinically led, locally integrated and quality focused.

The Quality Improvement strategy is closely aligned to core Trust strategies in particular the Clinical Strategy, and sets out how AWP will assure our services are of the highest quality and at the same time strive for continuous quality improvement.

Our quality improvement strategy articulates three broad quality objectives:

The creation of an organisational environment that allows good quality care to flourish

The establishment of a robust quality assurance framework which provides assurance of our quality


Delivery through agreed Quality Ambitions with Delivery Units and Corporate Directorates and the development of an integrated quality and safety plan to drive through the actions needed to achieve quality improvement

The Trust is quality regulated by the CQC (Care Quality Commission) and monitors, inspects and regulates our services to make sure they meet fundamental standards of quality and safety.

In May the CQC will inspect our services and will focus on the quality of services based on the five domains:

Safe

Effective

Caring

Responsive

Well led

The CQC inspected AWP in June 2014 and September 2014. Their report found that there were 71 compliance actions across 14 regulated activities and warning notices across 4 regulated activities (outstanding). In December 2014, the CQC re-inspected the Trust. They reported that the Trust’s actions in response to the warning notices were sufficient evidence of improvement to allow the warning notices to be lifted. This was formally reported in April 2015. All action plans were incorporated into the Trust’s Quality Improvement Plan, which continues to be closely monitored by the Quality and Standards Board Committee.

The CQC Programme Board has been established to oversee and scrutinise the work program to ensure we are prepared for Inspection in May 2016, and it sets clear actions and milestones toward regulatory compliance.

The Trust has developed a Quality Information System IQ (Information for Quality) to support the Trust’s revised approach to quality governance, assurance and on-going improvement. The system

provides information from ‘Ward to Board’ to ensure that the Board is fully sighted on matters of quality.

The Quality Assurance Framework illustrates the structural mechanisms which have been established from Board level through to local teams to ensure effective quality governance and clarifies lines of responsibility and reporting.

The key structures within the Quality Assurance Framework are as follows:

Quality and Standards Committee

Quality Improvement

Safety, Safeguarding

Patient experience

Mental Health Legislation

Learning from events, reviews and incidents

Regulatory compliance.

Management Groups – Monitoring Aspects of Clinical Quality; Providing Assurance to the Quality and Standards Committee

Service User Carer Steering Group

Critical Incident Overview Group

Infection control, physical healthcare and medical devices

Clinical Systems Group

Mental Health Legislation Management Group

Medicines Management

Integrated Governance Group

Professional Council

This is a clinical leadership group reporting to the Senior Management Team.

Specialist and Local Governance Groups

These are local delivery units operate governance groups to oversee compliance with quality standards, delivery of local improvement plans and risk management.

The development of our Quality Account is part of an important process involving engagement with stakeholders at different


levels and working together to agree quality priorities for the year ahead. The Quality Account priorities for 2015/16 are shared with staff, service users, carers and clinical commissioning groups (CCGs). The initial themes were discussed at the Integrated Governance Group and then worked up into indicators to track achievement against these. Wider comment is sought and received from our local health overview and scrutiny committees (HOSCs), the local Healthwatch, and the Trust wide Service User Involvement Group.

This ensures the annual operating plan priorities reflect the key quality priorities for our trust. These key indicators will form the primary framework for quality monitoring and reporting to Board, our commissioners and the public via our Quality Account.

National Audit The Trust has a diverse and responsive audit programme of 60 to 90 projects per year. This includes projects which are requested by single teams or individual clinicians, localities, trust wide priorities and national projects. We participate in all of National Audits and Clinical Outcome Programmes required. In 2015-16 we participated in the National Audits overseen by the Royal College of Psychiatrists and the National Confidential Enquiry into Suicides and Homicides. In addition we had 20 Trust Wide Projects, 5 small group projects (for example non-medical prescribers group), 30 Locality priority projects and 32 additional local projects. Topics include prescribing, record keeping, risk assessment, mental health act and many others.

Information for Quality (IQ) The Trust reviewed and introduced a revised component of the IQ system, which ensured a robust system of monitoring compliance with the Care Quality Commission’s Essential Quality and Safety Outcomes. In addition, the IQ system was further refreshed to ensure that it was aligned with other key

regulatory and contractual frameworks in six additional key areas:

Performance with the agreed contractual requirements, Monitor and CQUIN indicators

Sickness Absence rates

Compliance with Records Management standards

Financial balance

Supervision and Appraisal rates

Service user experience

This information is reviewed at our fortnightly Quality Huddle which takes place at Trust HQ with the Executive Team and representatives of all localities in attendance. The Quality Huddle methodology was refined by opening it up to leadership by a range of Trust senior managers, reinforcing accountability and ownership by and with senior managers.

Control measures are in place to ensure that all the Trust’s obligations under equality, diversity and human rights legislation are complied with.

Capacity to Handle Risk The Trust recognises that effective management of risk is a fundamental principle in the provision of high quality services and understands the need for a robust system for the identification and management of risks.

As Accountable Officer I am the Executive Director on the Trust Board with overall accountability for risk management, supported by the Director of Corporate Affairs. The Director of Corporate Affairs ensures a sound system of internal control is in place in respect of risk management, including the development of the Risk Management Strategy and policy for the identification, assessment and management of risks.

In 2015 we further developed our Risk Management Strategy. The Strategy sets the Trust’s approach to managing the risks to


our objectives and importantly the extent of the risk we are prepared to tolerate to the achievement of our objectives in a revised Statement of Risk Appetite.

I have delegated responsibility for management of areas of risk as follows:

Business Executive

Director of Resources

Business risk, including financial, human resources, workforce, corporate, business development, IM&T and estates risks.

Clinical Executive

Director of Nursing

Medical Director

Clinical risk, including nursing, medical, pharmaceutical, health and safety and safeguarding risks.

Delivery Executive

Director of Operations

Delivery risk, including risks escalated from the Trust’s localities and operational resilience risk

Oversight Oversight of risk management systems is delegated by the Trust Board to the Audit and Risk Committee, reporting to the Board via the Non-Executive Chair of the Committee. The Audit and Risk Committee seeks assurance of the integrity and efficiency of the management of risk in relation to the Trust’s financial, governance and clinical operations.

The Finance and Planning Committee plays a key role in managing financial risk and ensuring that resources are used economically and prudently.

The Quality and Standards Committee provides assurance in relation to all aspects of quality and associated risks.

Localities The day-to-day management of operational risk is devolved to our Locality Delivery Units (LDUs) with Clinical Directors held accountable for risk management within their LDU.

Management oversight is maintained through the meetings of the Directors’ Team (Executives and Clinical Directors) and through the Audit and Risk Committee which scrutinises one LDU risk register in detail at each meeting.

Training In 2015/16 the Trust provided four training sessions on risk management for senior managers and ad hoc training to a number of managers and other staff across the organisation.

In 2016/17 we will broaden our risk management training programme to include all managers.

Continuous Improvement The Trust Board encourages a culture of continuous improvement through its strategic priority, “continually improving what we do”. We seek to learn from good practice through a range of methods including responding to national guidance/alerts, benchmarking, clinical supervision and reflective practice, individual and peer reviews across clinical and non-clinical areas, performance management, continuing professional development programmes, clinical audit and application of evidence-based practice and meeting risk management standards.

Sharing of good practice across the Trust is facilitated through:

Directors’ Team meetings, which bring together our Executive Team and all Clinical Directors;

Board Committees, which receive assurances over activity in all our LDUs and SDUs; and

Dissemination of information via monthly supervision sessions undertaken with all staff.

Our electronic patient safety system and the extension of this for risk management purposes


Workshops and Training Events led by both External Facilitators and the Head of Risk and Legal Services to share good practice and develop risk ‘skills’.

Three monthly Risk ‘clinics’ to trouble shoot risk registers and ensure they are fit for purpose.

The Risk and Control Framework

Leadership Board of Directors

All Non-Executive Directors are deemed to be independent. The Board endeavours to conduct its business in an open and transparent manner, with the vast majority of the business of every Board meeting held in public.

The meetings are held at varying locations across the Trust if business allows and members of the public are welcomed to all meetings in part one. Public questions are invited both before and during the meeting.

The Board regularly assesses its own performance, and spends time at each Board meeting reflecting on successes and areas for improvement using a set methodology for evaluation. The Trust surveys Board and Committee members annually using an online survey tool based on best practice evaluation methodologies.

The Board welcomes presentations, films and ‘stories’ from patients, service users and carers to review quality of service and experience, and to guide the Trust in continually learning from feedback and improving our services.

Board Membership

In line with Monitor Code of Governance requirements, the Chair keeps under active review the appropriateness of board membership and the independence of Non-Executive Directors.

We make sure that the balance of skills, expertise and experience of the Board of

Directors is sufficient through a process of skills mix review and analysis of recruitment needs when new Directors are recruited. With the Trust Development Authority Appointments Department, all new Non-Executive Director appointments are scoped carefully to mirror skills and experience gaps in the board composition.

All Non-Executive Directors are considered to be independent as they have not been employed by the Trust and do not have any financial or other business interest in the organisation. None have close family ties with the Trust’s advisors, directors or senior employees and none has served on the Board of Directors of the Trust for more than nine years.

No Board Director has declared any significant interest in any company with which the Trust is likely to do or seeking to do business with at this time. A Register of Directors’ Interests is maintained by the Director of Corporate Affairs. This is reviewed by the Audit and Risk Committee.

Whilst the Chairman has taken on the Chairmanship of the South West Genomics Council in 2015, this has not affected the time he dedicates to his role as Chairman of the Trust, and therefore is not deemed to equate to a significant change in the Chair’s commitments during the year.

Board Committees

The Board’s sub-Committees are all chaired by Non-Executive Directors. Committee structures are reviewed annually and changes made to reflect learning and best practice.

The Board reduced its committee structure in 2015, choosing to merge its Quality and Standards Committee with its Employee Strategy and Engagement Committee. This followed a decision to convene a strategic workforce group to offer management assurance on delivery of key elements of the workforce agenda in its place. The assurance and governance arrangements have become further embedded over the


course of the year. The structure can be viewed at appendix 1.

Having commissioned an independent review of the effectiveness of its Committees in 2014/15 and made recommendations about how the Trust could realise greater benefit from the work of its Committees through clearer lines of assurance and accountability; the Board spent 15/16 working to ensure these plans were implementing, systematically working through the Board Development Action Plan. The actions are 80% delivered at year end, having been delayed deliberately to allow a period of reflection by the new Director of Nursing. The continuous improvement and learning on the part of the board continues as it embarks on another process of evaluation and review scheduled for early 2016/17.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

The Trust has undertaken environmental risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

Performance against Key Indicators

The NHS Trust Development Authority (TDA) monitored our Trust against Monitor’s standards throughout the year. The Trust Board received and reviewed monthly performance reports.

Every month, via the AWP website, we provide our ‘in month’ performance in relation to all nationally recognised service quality measures, so that comparisons can be made with other mental health service providers. 2015-16 saw three new national ‘access and waiting time’ indicators introduced for Mental Health Trusts as part of the Parity of Esteem agenda, and AWP has been monitoring these locally since June 2015.

Over the last 12 months the Trust achieved the following results against national indicators:

Performance against key indicators 2015/16

Indicator Target Result

7 day follow-up to discharge

95% 97%

Gate-keeping of inpatient beds

95% 92%

Service users receiving an annual review

95% 97%

Delayed Transfers of Care <=7.5% 8.9%

New cases of first episode psychosis

182 cases 288

Data Quality: completeness of identifiers

97% 99%

Data Quality: completeness of outcomes

50% 82%

Referral to treatment: first episode psychosis

50% 84%

Referral to treatment: IAPT services (within 6 weeks)

75% 92%

Referral to treatment: IAPT services (within 18 weeks)

95% 99%

We have used a “traffic light” system to rate how well we have done against the indicators. These are:

Red Standard not met/poor result

Amber Standard nearly met/adequate result

Green Standard met/good result

The Trust is above target for all but two indicators, namely, Delayed Transfers of Care and the gate-keeping of admissions.


During 2015-16, the Trust has worked to understand the root causes of the under-performance so that plans can be put in place to deliver improvement.

For the gate-keeping of admissions, these plans are well developed and the Trust is forecasting improvement early in 2016-17. For delayed transfers of care, the Trust continues to experience difficulty in finding appropriate care home placements for some service users.

Management The Trust’s Risk Management Strategy outlines the leadership, responsibility and accountability arrangements for risk management. These arrangements are demonstrated through the Board Assurance Dashboards, the Trust’s risk registers, its business planning processes and its quality monitoring systems enabling the coherent and effective delivery of risk management throughout the organisation. The Trust’s approach to risk is to ensure that risks are systematically assessed and mitigate. It is not possible to eliminate all of our risks

Trust Board revised its risk appetite in 2015/16 to provide clear direction to staff about the extent of risk to its objectives the Trust can tolerate. These are stated within the Risk Management Strategy. Where risks to our objectives cannot be eliminated they will be mitigated to an acceptable level. The Trust Risk Management Strategy sets out strict criteria for when a risk may be considered ‘accepted’.

The Trust undertakes regular reviews of its risk management arrangements and wider internal control framework and in 2015/16 an internal audit granted the Trust amber-green assurance as to the effectiveness of our processes.

In addition both Internal Audit and External Audit have been sighted on the preparation of the annual governance statement.

The Risk Management Strategy is underpinned by the Risk Management Policy

which defines processes for risk identification, assessment, evaluation and mitigation. The Risk Management Policy works in conjunction with the Incident Policy which describes how incidents will be reported and managed and identifies the processes that must be adopted in the event of a serious untoward event.

During 2015/16 the Trust began the implementation of a new electronic database for managing risk registers that will deliver further improvements to the management of the risks to our objectives.

The Trust has continually sought to increase the level of incident reporting as a means of identifying and acting upon risks which was reflected in our 2015 staff survey results where our staff reported more incidents than the national average.

The Trust aims to systematically review and learn from untoward incidents and complaints. Good practice and changes to policies are communicated through Policy Alerts, newsletters and through dissemination by senior management. We share safety information via specific Trust-wide Red-Top Alerts to ensure immediate communication is received by staff on significant and priority issues.

There are formal mechanisms in place to ensure that external changes to best practice are incorporated into Trust policies, procedures and clinical guidelines.

Systems exist in the Trust for the identification, assessment and analysis of risk and the Trust uses its risk register to capture and report on risks to the achievement of objectives. Different types of risk are measured with a common scoring matrix and significant/key risks have been identified, assessed and managed. A programme of action, management and control is required for each significant risk.

Systematic identification of risks is undertaken using the Trust’s risk registers. The Trust-wide risk register captures both


high-level operational and our strategic risks and is underpinned and informed by the Executive and directorate, with routes for upward reporting set out in the policy framework. Each director is accountable for maintaining a register of risks that fall within their area of responsibility.

Quality risks are captured within departmental risk registers and significant risks are escalated to the Clinical Executive risk register.

Information governance and data security risks are managed as part of this process. Risks are assessed using the Information Governance Toolkit and captured on the risk register.

The Trust has a Data Quality Management Strategy which is the responsibility of the Executive Director of Resources. Assurance regarding Data Quality is provided through the Business and Clinical Systems Group.

The Board Assurance Dashboards were developed in year. Intended to give the Executive an overview of all risks to the achievement of Trust objectives and the underpinning controls and assurances, the Assurance Dashboards were reviewed at Trust Board every quarter.

The Trust commenced assessment of its compliance with the Monitor’s Well Led Framework, and will continue this work into 2016/17.

The key in year risks facing the organisation which have been managed and mitigated at Board level are:

Ref Risk description

63 If staff cannot be effectively engaged in Bristol then changes cannot be made to meet the requirements of the new service model.

TW7 Failure to manage capacity leading to further pressure on existing resources potentially compromising patient care

CE16 If we are unable to resolve the issues identified in the CQC s29 Warning Notice issued in December then we may receive

a negative rating from the CQC.

AGS1 Serious quality failure event if the Trust's quality system fails to proactively identify areas of poor practice.

IBP12 Sub-optimal estate/failure to ensure productive use of Trust's estate to manage demand and cost/ensure fitness for purpose.

AGS7 The Trust becomes a loss-making or financially non-viable business

AGS6 AGS6: Failure to Maximise our position in the health economy if we are unable to respond to opportunities for growth and development.

The key future risks, in addition to the above, are:

1 If service users are not treated as equal partners in the creation of consistent care standards and care pathways – then co-production will be delayed and the achievement of the objective will suffer.

2 If we do not maximise the levels of engagement within our workforce, then we will not have the opportunity for staff to feel part of ‘the solution’ and to identify poor practice and become change agents. The Charter will therefore be unsuccessful as a tool for staff engagement and improvement for cultural change: ‘One Trust’

3 If we cannot maximise the opportunities to work with our public health, voluntary, and third sector partners within the system, who specialise in preventative aspects of healthcare; then we may lose opportunities to improve physical healthcare for our population.

4 If we do not retain our current business and achieve new business in line with our strategic plan, then we may not achieve our financial targets.

5 If sufficient resources are not available to support our contribution to the STP work in both local areas, then the value of the planning work will not be derived and the prioritisation of mental health will not be achieved.

In accordance with Condition FT4 of the Monitor Provider Licence relating to governance arrangements, the Trust Board has continued to ensure that there are consistent systems in place to ensure:


The effectiveness of governance structures,

The responsibilities of directors and subcommittees;

Reporting lines and accountabilities between the board, its subcommittees and the executive team;

The submission of timely and accurate information to assess risk; and

The degree and rigour of oversight the board has over the trust’s performance.

As a result, the Board confirms that it has complied with Condition FT4 in-year, as far as is appropriate for an aspirant Foundation Trust, to date and that it expects to continue to comply with this condition throughout 2016/17.

Review of Economy, Efficiency and Effectiveness of the Use of Resources The Trust’s Integrated Business Plan and Annual Operating Plan are approved by the Board of Directors and submitted to NHS Improvement (formerly the Trust Development Authority). Delivery against the Annual Operating Plan via the Trust’s annual objectives is monitored in detail by the Board of Directors on a quarterly basis using the Assurance Dashboard approach.

Detailed monthly financial and integrated quality and performance reports are reviewed by the Finance and Planning Committee and are made available to all members of the Trust Board, the Trust’s External Auditors and NHS Improvement. The Chair of the Committee provides a report to the Trust Board after each meeting of the Committee.

The Trust’s resources are managed within the framework defined in its Standing Financial Instructions. Financial governance arrangements are supported by internal and external audit to ensure economic, efficient and effective use of resources.

Information Governance The Executive Director of Resources is the senior information risk owner (SIRO) with responsibility for managing information security risks at Board level.

The Trust has reported 16 (as of 31/03/2016) level two Information Commissioner reportable information security breaches in 2015/16. In addition, the Trust invited the Information Commissioner to carry out an Information Compliance Audit and the Trust received limited assurance, and is working to deliver actions to mitigate this position to a reasonable level.

The Information Governance Toolkit version 13 return in year, achieved a return of 77%, which is satisfactory (as of 31/03/2016).

Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare a Quality Account for each financial year. The Department of Health has issued guidance to NHS Trust Boards on the form and content of annual Quality Reports which incorporate the above legal requirements.

The Directors of Avon and Wiltshire Mental Health Partnership NHS Trust are required to satisfy themselves that the Trust’s annual Quality Account is fairly stated. In doing so the Trust is required to put in place a system of internal control to ensure that proper arrangements are in place.

The Chief Executive and Chair have signed a statement on behalf of the Board to confirm that Directors have taken steps in preparing the Quality Account to satisfy themselves that:

The Quality Account presents a balanced picture of the Trust’s performance over the period covered.


The performance information reported in the Quality Account is reliable and accurate.

There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account; and these controls are subject to review to confirm that they are working effectively in practice.

The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review.

The Quality Account has been prepared in accordance with Department of Health guidance, subject to external audit and is to be submitted by the agreed deadline of 30 June 2016.

The Trust has prepared its Quality Account for 2015/16 and this gives a meaningful insight into how we are doing in relation to our aspirations, including an honest review of the progress we have made on the priorities we set last financial year and the work that remains for us to do.

Our Quality Account has been developed in partnership with our service users, carers, clinicians, managers, commissioners, Healthwatch and local authority health overview and scrutiny committees.

Review of Effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me.

My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit and Risk Committee and Quality and Standards Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place.

The Board Assurance Framework and Assurance Dashboards provides me with evidence that we are controlling the risks to our annual objectives.

The Head of Internal Audit has provided me with a draft opinion as follows:

‘The organisation has an adequate and effective framework for risk management, governance and internal control.

However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective.’

My review is also informed by:

Board review of our Board Assurance Dashboard and action plans

Audit and Risk Committee scrutiny of controls in place

Review of serious incidents and learning by the Quality and Standards Committee

Review and challenge from non-executive directors within committees and at the Board

Challenge of Trust-wide risk register and individual directorate risk registers by the Directors Team which consists of all Clinical Directors and Executive Directors

Internal audits of effectiveness of systems of internal control

Counter Fraud Specialist reviews of fraud control and deterrent activity

Effectiveness reviews undertaken by DAC Beachcroft as described within this


statement and subsequent improvement action taken

NHS Litigation Authority assessments

Conclusion The Board has concluded that there are no significant internal control issues identified.

Chief Executive

25th May 2016


Appendix 1 – Governance arrangements Board membership

The members of the Board of Directors during the year were:

Name Role Committees

Anthony Gallagher Chair of the Trust Appointments

Remuneration

Susan Thompson Vice Chair

Appointments

Quality and Standards (Chair)

Remuneration

Lee O’Bryan Senior Independent Director and

Non-Executive Director

Appointments

Finance and Planning (Chair to 14 October 2014)

Remuneration

Ruth Brunt Non-Executive Director

Appointments

Charitable Funds

Employee Strategy and Engagement (Chair)

Quality and Standards

Remuneration

Barry Dennington Non-Executive Director

Appointments

Finance and Planning (Member from 1 February 2015. Chair from 20 November 2015))

Quality and Standards (from 1 February 2015)

Remuneration

Peaches Golding Non-Executive Director

Appointments

Audit and Risk

Charitable Funds (Chair)

Employee Strategy and Engagement Committee

Remuneration

Tony McNiff Non-Executive Director

Appointments

Audit and Risk (Chair)

Remuneration

Graham Coxell (Associate) Associate Non-Executive Director Finance and Planning Committee (in attendance only)

Iain Tulley

Chief Executive (to 31 January 2016)

(Accountable Officer to 30 November 2015)

Appointments

Hayley Richards

Executive Medical Director and Deputy Chief Executive

Acting Chief Executive (Accountable Officer from 1 December 2015)


Appointments (from 1 February 2016)

Sue Hall Executive Director of Resources

Audit & Risk (in attendance)

Charitable Funds

Employee Strategy and Engagement

Finance and Planning

Kristin Dominy Executive Director of Operations (to 21 August 2015)



Quality and Standards (in attendance only)


Andrew Dean Executive Director of Nursing (from 16 March 2015)

Audit & Risk (in attendance)


Mathew Page Interim Director of Operations (from 22 June 2015)


Quality and Standards (in attendance)

Tim Williams Acting Medical Director (from January 2016)

Audit and Risk (in attendance)


Ernie Messer Associate Non-Executive Director (from 1 February 2016)

Remuneration

Appointments

Finance and Planning (in attendance)

Mark Outhwaite Non-Executive Director (from 1 February 2016)

Remuneration

Appointments


Charlotte Moar Non-Executive Director (from 1 February 2016)

Remuneration

Appointments

Audit and Risk (Chair)

Board member attendance

The Trust Board attendance record during 2015/16 was:

Director Number of meetings attended (total available)

Anthony Gallagher 9 (10)

Susan Thompson 7 (10)

Lee O’Bryan 5 (6)

Ruth Brunt 7 (10)

Barry Dennington 6 (10)

Peaches Golding 8 (10)

Tony McNiff 2 (4)

Graham Coxell (Associate)* 2 (5)

Iain Tulley 8 (8)

Hayley Richards 8 (10)

Sue Hall 9 (10)

Kristin Dominy 2 (4)

Andrew Dean 8 (10)

Mathew Page 6 (6)

Tim Williams 3 (3)

Ernie Messer (Associate) 2 (2)

Mark Outhwaite 2 (2)

Charlotte Moar 1 (2)

* Associate Directors are not required to attend Board meetings and their role is as advisor to the Board.


Appointment of Non-Executive Board members

The length of appointment of each Director is as follows:

Name Start of Appointment End of Appointment (actual or contracted)

Anthony Gallagher

Appointed as Interim Chair

Appointed as Chair

1 May 2008

25 April 2012

12 July 2012

24 April 2012

11 July 2012

11 July 2016

Susan Thompson

Reappointed

1 December 2008

30 November 2012

30 November 2012

30 November 2016

Lee O’Bryan 14 October 2011 14 October 2015

Ruth Brunt (Associate) 1 February 2013 30 November 2013

Ruth Brunt 1 December 2013 30 November 2017

Peaches Golding 1 June 2013 31 May 2017

Barry Dennington 17 August 2014 16 August 2016

Tony McNiff 1 March 2012 29 February 2016

Graham Coxell (Associate) 1 April 2014 31 March 2018

Charlotte Moar 1 February 2016 31 January 2020

Mark Outhwaite 1 February 2016 31 January 2020

Ernie Messer (Associate) 1 February 2016 (No end date)


Trust Board

Nominations Committee

Audit and Risk Committee

Remuneration Committee

Charitable Funds Employee Strategy and Engagement

Committee *

Finance and Planning Committee


Committee

Board Committees

*This Committee was deleted in January 2016

The role of each Committee is defined as follows:

Committee Role

Appointments Committee To conduct the formal appointment to, and removal from office of the Board of Directors.

Nominations to conduct the formal appointment to, and removal from office of the Board of Directors

Audit and Risk Committee to assess whether our Trust’s systems and processes for governance, risk management and internal control are fit for purpose, and are being applied appropriately and effectively; and, to report to the Board on its findings

Remuneration Committee to agree policy and frameworks for executive and senior officer remuneration

Finance and Planning Committee to provide specialist financial and commercial scrutiny and oversight

Quality and Standards Committee to monitor, review and report to the Board on the standards of quality, compliance and performance of Trust services (this committee was merged with the Employee Strategy and Engagement Committee in January 2016 and assumed its duties)

Employee Strategy and Engagement Committee

to monitor, review and report to the Board on approaches to employee engagement and the effectiveness of employee facing policy and strategy

Charitable Funds Committee to monitor the application of all charitable funds in accordance with the Charities Acts, external guidance and applicable legislation, and to ensure that decisions on the use or investment of such funds are compliant with the explicit conditions or purpose for each donation, bequest or grant.

Designated Committees Statutory Committees


Disclosures in the Public Interest

Corporate governance Membership of the Board of Directors

Anthony Gallagher, Chairman

Tony has over 25 years’ leadership experience at Board level in Financial and Operational teams in Electronics both in European and US multi-national companies. As Chief Financial Officer,

Tony has led international finance teams through major change initiatives including significant M&A projects which changed strategic direction in markets and technology.

As Vice President of a quoted US company, Tony led a Asian outsourced strategy and was instrumental in implementing lean manufacturing teams across international teams. Changing scale, Tony was Chief Operating Officer for a UK based Semiconductor company leading Finance, Operations, HR and all engineering functions.

Tony advises several smaller scale hi-tech companies on Financial, Operational and Strategic issues. His education includes degrees in Economics and Business Administration and he is a qualified accountant. Previously Tony was Chair of a further education college.

Susan Thompson, Vice Chair

Susan is a practising solicitor with 30 years' experience and is a partner at DAC Beachcroft LLP, an international commercial law firm, based in their Bristol office. Much of her legal career has been

advising and defending health and social care organisations and she brings to the Board a background of knowledge advising the NHS on risk, quality, governance and

person-centred issues. She has a strong commitment to person centred care in mental health services from her experience as a lawyer with a human rights focus and it is her work experiences which motivated her to seek this appointment.

Susan is a former Chair of the Law Society’s influential Mental Health and Disability Committee which seeks to influence law and policy and support lawyers practising in this field and was a member from 2005-2014.

Lee O’Bryan, Senior Independent Director (until 14 October 2015)

After a career in Royal Mail, Lee now runs an HR and Change Management consultancy, working with both public and private sector clients across the UK. During his time with Royal Mail Lee held a

variety of Board level roles including Regional Operations Director, Head of Transformation and UK HR Director for the Commercial Business Unit. Lee has also worked for the Economic and Social Research Council and Birkbeck College. He is a Fellow of the Chartered Institute of Personnel and Development, and a UK accredited mediator. Lee is a member of the Avon and Somerset Constabulary/PCC, Audit Committee, and also a NED with Wiltshire based Selwood Housing Association, where he is Chair of the Group Remuneration/Employee and Governance Committees. Lee is the Statutory Independent Person for Bath and North East Somerset, a voluntary role involving review of complaints about councillors.

Ruth Brunt, Non-Executive Director

Ruth Brunt is a former Chief Executive of North Bristol NHS Trust.

Ruth brings to the Trust some 40 years' NHS experience through a wide ranging career

encompassing roles in hospital nursing, midwifery, district nursing, nurse education


and management. Prior to retiring in Spring 2012, Ruth was chief executive of North Bristol NHS Trust, having joined that Trust in 2004 as Director of Nursing before becoming its Director of Operations. Prior to this she was Director of Nursing and Operations at Northern Devon Healthcare Trust and Director of Nursing for both North Devon and the Royal Devon and Exeter Hospitals for a year whilst they considered merger.

Barry Dennington, Non-Executive Director

Barry brings extensive leadership experience to the Trust. He brings a breadth of international business and management knowledge from Philips Electronics in his role as Senior Vice President and

as Managing Director of NXP UK Ltd. Most recently he was chief operating officer with Plessey. He has worked across the global electronic systems and microelectronics sectors. His experience includes setting up and leading operations in the USA, India, China and Europe, as well as serving on industry boards.

Alongside his international business career, Barry has lived in Wiltshire for many years and has remained committed to the area. He is chair of the Swindon and Wiltshire Local Enterprise Partnership and provides business support to small and medium sized companies.

Peaches Golding, Non-Executive Director

Peaches Golding OBE is a highly experienced executive and non-executive director. She is principal consultant of Moon Consulting Ltd, Chair of the ITV West Country Viewer Advisory Panel and

a Trustee of the SS Great Britain. Her previous involvement in the health sector includes Non-Executive Director roles with North Bristol NHS Trust and the General Chiropractic Council. She has valuable experience working in partnership with

public, private and voluntary sector, principally gained through regional and national leadership roles for Business in the Community (one of The Prince’s Charities) and as an advisor to regional and national public sector bodies.

Peaches is a former High Sheriff of Bristol. She was awarded the OBE for services to minority ethnic people in the South West in 2009 and awarded an honorary MBA by the University of the West of England in 2010. She is a Chartered Marketer of the Chartered Institute of Marketing and an Accredited Mediator.

Tony McNiff, Non-Executive Director (until 29 February 2016)

Tony is a consultant providing business support services to small and medium sized businesses across the West of England and Wales. Having obtained his Law Degree (LLB) at Southampton

University, Tony trained as a Chartered Accountant with KPMG. He has spent most of his professional career in Industry as a Finance Director and Group Financial Controller with the Christie Tyler Group and as Finance Director for FirstGroups bus division in Wales. He has also held senior financial roles at DVLA and the Royal Mint. Tony served four years as Managing Director of First’s bus division in Wales and then subsequently as Managing Director of First’s bus interests across both Wales and the West of England. During this time he chaired the Confederation for Passenger Transport in Wales.

Tony is a Fellow of the Institute of Chartered Accountants in England and Wales and fellow of the Chartered Institute of Logistics and Transport.


Graham Coxell, Associate Non-Executive Director (until October 2015)

Graham has a strong track record of leading companies through significant changes & growth, including acquisitions and partnerships

His working life has focused on leading "the growth and transformation of businesses through building clearly defined strategies which together with tight management, engaging cultures and cost control deliver compelling results."

In 2001 he became one of the youngest chief executives of a FTSE 250 company at the age of 31.

He currently holds a number of senior positions including executive chairman of the investment management company Rowan Dartington & Co, and chairman of the Forward Internet Group, a company that invests and acquires companies needing transformational growth capital. He is also chairman of JCA Occupational Psychologists, a company which helps organisations achieve greater success though getting the best from their people in a sustainable way.

As an Associate Non-executive Director, Graham was active in business case development and evaluation, and relationship management and attended Finance and Planning Committee meetings in an advisory capacity.

Charlotte Moar, Non-Executive Director (from 1 February 2016)

Charlotte Moar is a qualified accountant with wide experience in finance, business planning, performance management and informatics.

She is currently Programme Director of NHS Wales Finance Academy. Prior to this, Charlotte held Finance Director/Deputy Chief Executive posts with Cardiff & Vale University Health Board, NHS

England (South), South Central Strategic Health Authority, NHS Wiltshire, and Great Western Hospitals Foundation Trust. Prior to joining the NHS, she worked in industry, in the theatre and in publishing.

Charlotte is also a member of the Audit and Risk Committee of the Medical Research Council and a Trustee of Bristol Zoological Gardens.

Mark Outhwaite, Non-Executive Director (from 1 February 2016)

Mark runs his own consulting business specialising in coaching, change management and organisational development support, mainly to public sector organisations. He also has a

long term interest in the challenges of technology implementation and provides advice and support to tech start-ups in the healthcare sector. At the core of all his approaches is user engagement in co-design and co-production from inception to implementation and beyond.

Mark started his career as an Army Officer and subsequently became a NHS Chief Executive firstly in a Family Health Services Authority and subsequently in Health Authorities. He left the NHS to set up his own business after a final stint as a director of the NHS Modernisation Agency.

Ernie Messer, Associate Non-Executive Director (from 1 February 2016)

Ernie has a broad general management career starting in the commercial sector, with senior roles in Retail Financial Services; Human Resources; IT and large scale Strategic Change. 8 years ago he

switched to the not for profit / charity sector specialising in governance; creating high performing leadership teams and successful collaboration between organisations. He is a consultant at Cass Business School's Centre for Charity Effectiveness in London where


work includes helping clients delivering mental health services and social care provision. He also teaches on their MSc programme on the "Managing People & Quality" module.

Iain Tulley, Chief Executive

Iain Tulley has 13 years' experience as a chief executive and over 30 years' experience in healthcare, predominately in mental health. Prior to joining the Trust, Iain was chief executive of

Devon Partnership NHS Trust and has held numerous senior posts including working in the Department of Health and as Director of Planning and Performance for the former Wiltshire Health Authority. He is a strong advocate of clinical leadership and describes the quality of the patient experience as his only priority. Iain began his career in Scotland as a registered mental health nurse, has strong commissioning and provider experience and a good track record of partnership working. He has substantial experience of driving performance improvement and delivering organisational change and was actively involved in the development of the National Service Framework for mental health services.

Iain was the Chief Executive of the Trust until 30 November 2015.

Hayley Richards, Executive Medical Director and Deputy Chief Executive (until 30 November 2015), Acting Chief Executive (from 1 December 2015 until 12 April 2016), Chief Executive (from 12 April 2016)

Hayley qualified in medicine from the University of Bristol in 1986 and became a member of the Royal College of Psychiatrists in 1993. Prior to her appointment as Medical Director, Hayley

was the Trust's Director of Medical Education, chair of the Liaison and Later Life strategic business unit Medical Advisory

Group and a Consultant Psychiatrist for older people. Hayley's expertise includes both general and old age psychiatry.

In addition Hayley has been a supervisor to advanced psychiatric trainees and associate specialist doctor, and a College Approved Advisor to Deaneries.

After some delay, we were able to announce that Hayley had been confirmed as our Chief Executive on 12 April 2016. Appointments of this kind are subject to ministerial approval and we were unable to make the announcement until that had taken place.

Sue Hall, Executive Director of Resources

Sue is a Chartered Management Accountant with over 20 years’ experience of working in Senior Finance roles both within the public and private sectors including higher education, car

rental, local government and latterly the health service including establishing a new Primary Care Centre working with GPs. She joined the Trust from Great Western Hospital NHS Foundation Trust where she had worked as Deputy Director of Finance for five years, and was heavily involved in the successful merger of Wiltshire Community Health Services with the acute trust and also the journey in 2007/08 from NHS trust to a foundation trust. Sue is committed to the ideal of world class finance underpinning the delivery of excellence in healthcare and believes this is achievable throughout the NHS.


Dan Meron, Acting Executive Medical Director (1 December 2015 – January 2016)

Dan joined AWP in 2005 as a Senior House Officer, and after taking up a Consultant post, went on to fulfil several leadership roles before becoming

Deputy Medical Director in 2014.

In January 2015, he left to take on the role of Chief Medical Officer at Solent NHS Trust.

Tim Williams, Acting Executive Medical Director (January 2016)

Tim studied Medicine at the University of Sheffield, and completed dual academic psychiatry training in Severn Deanery with the University of Bristol. He went on to become a consultant in

Addiction Psychiatry in Bristol and South Gloucestershire. He completed a Medical Doctorate with the University of Bristol in Neuropsychopharmacology. He was the Clinical Director for Specialised Services in AWP responsible for criminal justice services, personality disorder services, learning disability services, veterans services, deaf mental health services, autism services, eating disorder services, ADHD services, mother and baby inpatient services, and four community and one inpatient drug and alcohol services.

He is an Honorary Senior Clinical Lecturer with the University of Bristol and continues with his research interests collaborating mainly with Imperial College, London. He has written risk assessment reports for the Home Office ACMD committee and continues as a national expert in Novel Psychoactive Substances Neptune committee. He is a member of DrugScience a national expert group that produces research and advice on evidence based drug and alcohol policy, science and law.

Kristin Dominy, Executive Director of Operations (until 21 August 2015)

Before taking up her role as Operations Director, Kris was service director for the Trust's specialist drug and alcohol service and acting interim area director for South Gloucestershire. The role of operations director

provides an important bridge between the clinical delivery work of medical and nursing colleagues and the enabling work of finance and HR. As operations director, Kris is accountable to the Board for the work of the local management teams in delivering services and for ensuring that they meet local requirements. Kris has led Specialist Drugs and Alcohol Service (SDAS) since 2009, having previously worked in Bristol as an SDAS service manager. Before joining the Trust, Kris worked in London for both the Healthcare Commission and the National Treatment Agency.

Mathew Page, Acting Executive Director of Operations (from 22 August 2015)

Mathew qualified as a Mental Health Nurse in 1999 and specialised in Intensive Care and Low Secure services before entering senior

management. Prior to his current role he was the Service Director for the Children and Young People Service of 2gether Foundation Trust. He joined Avon and Wiltshire Partnership Trust in October 2014.

Mathew has published a number of articles and book chapters mostly relating to nursing practice development and is a strong advocate of the necessity of innovation in service improvement.

In 2015 Mathew launched the National Minimum Standards for Psychiatric Intensive Care Units for Young People for which he was the lead author.


Mathew believes in the benefits of working in partnership with other agencies in particular the voluntary and community sector, having previously managed and commissioned successful partnership service models.

Andrew Dean, Executive Director of Nursing and Quality

Andrew Dean joins the Trust with a wealth of experience of delivering mental health services within the public and private sectors, with a number of years at executive level. He is

fundamentally committed to improving quality and patient care and nursing as a profession, and has previously run a nursing development unit. His previous roles have included Director of Operations, Chief Operating Officer and Specialist Commissioner as well as Director of Nursing. He was the executive lead for the successful 2014 Chief Inspector of Hospital’s inspection at South West London and St. George’s NHS Mental Health Trust where he was the Director of Nursing and Quality Standards.

Trust Board employment terms

The Chair and Non- Executive Directors of our Trust have been appointed by the Secretary of State for Health, the Appointments Commission or the NHS Trust Development Authority, with a term of office of up to four years. This can be renewed for a second four year term.

All Executive Directors of our Trust for the year are on permanent contracts and have a notice period of six months.

Board member skill mix

In line with Monitor Code of Governance requirements, the Chair keeps under active review the appropriateness of board membership and the independence of Non-Executive Directors. He ensures that the balance of skills, expertise and experience of the Board of Directors provides effective and proactive leadership through a process of

skills mix review and analysis of recruitment needs when new Directors are recruited. With the Trust Development Authority Appointments Department, all new Non-Executive Director appointments are carefully considered to mirror skills and experience gaps in the board composition.

Board performance evaluation

The Trust ensures that it regularly invites external reviews of its governance arrangements. During 2013 and 2014 the Trust saw focused reviews of its Board, Committees and management groups undertaken by DAC Beachcroft, and concentrated on implementation of actions arising from these reviews during 2015.

The Board worked systematically, through 2015 to implement best practice through the delivery of its board development action plan; a delivery plan which set out its stretch targets identified through its external board evaluation and a series of additional development sessions, alongside performance review sessions.

The Board and Board Committees, at each meeting carry out an information evaluation using an agreed consistent methodology, with all attendees including governance support staff rating the meeting 1-4 using a series of categories. The Board and Board Committees undertaken a more formal survey of effectiveness annually using an online survey tool and the results are discussed shared, transparently and used to focus the development activities for the year, and the improvements to the governance support and corporate governance frameworks.

Board member performance appraisal

The Chief Executive is responsible for undertaking the appraisal of the Executive

Directors in line with the Trust appraisal process, and Directors are required to demonstrate board level leadership behaviours as defined in job descriptions.

The appraisal of the Chief Executive is conducted by the Chair (or the Senior Independent Director in his absence), and utilises a 360 degree feedback mechanism,


in line with Trust policy, which gathers feedback from a range of stakeholders.

The appraisal of the Chair is conducted by the Trust Development Authority, using a 360 degree feedback mechanism. The Chair appraises the Non-Executive Directors using the Trust adopted process, and also meets regularly to review achievement of objectives and development needs.

All Executive and Non-Executive Directors are appraised annually.

Attendance at meetings

Board member attendance at Board meetings is reported within the Annual Governance Statement from page 26 of this report.

Committee memberships

The membership of the sub-Committees of the Trust Board during 2015/16 was as follows:


Committee Chair Member Member Member Member Member Member Member Member

Appointments Anthony Gallagher

Susan Thompson

Lee O’Bryan (to 14 Oct 2016)

Ruth Brunt Barry Dennington

Charlotte Moar (from 1 Feb 2016)

Mark Outhwaite (from 1 Feb 2016)

Ernie Messer (from 1 Feb 2016)

Audit and Risk Tony McNiff (to 31 Dec 2015)


Peaches Golding

Executive Director of Resources (in attendance)

Executive Medical Director (in attendance)

Director of Nursing and Quality (in attendance)

Charitable Funds

Peaches Golding Ruth Brunt Executive Director of Resources


(ceased August 2015)

Ruth Brunt Peaches Golding




Barry Dennington (from 22 Oct 2015)



Executive Director of Operations



Susan Thompson Ruth Brunt Executive Medical Director

Director of Nursing and Quality

Executive Director of Operations (in attendance)

Remuneration Anthony Gallagher

Susan Thompson


Ruth Brunt Barry Dennington



Ernie Messer (from 1 Feb 2016)

Chief Executive


Directors’ interests The NHS Code of Accountability requires Trust Board members to declare interests which are relevant and material to the NHS Board of which they are a member.

The Trust’s Standing Orders define this requirement. Members of the Board of Directors must declare on appointment any interests, which might place, or be seen to place them in a potential conflict of interest between their personal or private interest and those arising from their membership of the Board of Directors. Board Directors are also required to declare any conflict of interest that arises in the course of conducting Trust Business, specifically at each meeting of the Board and its Committees.

Register of Interests

Interests declared by Directors, current at 31 March 2016

Director Relevant and material Interests declared

Anthony Gallagher

None specified

Susan Thompson

Directorships of Companies and Partnerships of Non-incorporated bodies

DAC Beachcroft, Partner

Lee O’Bryan

Shareholdings in private or unquoted companies

The Camden Partnership Ltd


Selwood Housing Association, NED

Avon and Somerset Police/PCC, Independent Member Audit Committee

Ruth Brunt None specified

Interests declared by Directors, current at 31 March 2016 (continued)

Barry Dennington


Swindon and Wiltshire Local Enterprise Partnership, Chairman

Other possible conflicts of interest

Corsham Institute Board of Governors, Board Member

Executive coach

Peaches Golding

Membership of Committees operating in Trust area

Diversity Group, ITV West (Covering Gloucestershire, Bristol, BANES, North Somerset, Wiltshire)


Viewer Advisory Panel, ITV West Country, Chair

Tony McNiff


Ora et Labora Ltd, Director


Prior Park Educational Trust, Business Director

Graham Coxell


Rowan Dartington Holdings

JCA Psychologists


Rowan Dartington & Co Ltd/ Rowan Dartington Holdings, Chairman & Director

JCA Psychologists, Chairman & Director

Ardan International, Director

Forward Internet Group, Chairman & Director


Company in the Community/ Bristol Leadership Programme



Charlotte Moar




Trustee – Bristol Zoo

Member Audit and Risk Committee – Medical Research Council

Mark Outhwaite


Outhentics Consulting Ltd


Outhentics Consulting

HOIP CIC

In and Out Ltd


None specified

Ernie Messer None specified

Iain Tulley

Membership of Committees operating in Trust area

South Western Ambulance Service NHS Foundation Trust, Governor

West of England Academic Health Science Network, Director

Hayley Richards

None specified

Sue Hall


PJH Consulting Ltd

Raregift Ltd T/A Alison Miles Designer


Pound Arts Centre, Corsham, Chair of Trustees


University Hospitals Bristol Trust - Appointed Governor for AWP


Kristin Dominy None specified

Mathew Page None specified

Alan Metherall


Mental Health Connections Ltd


Treasurer - National Association of Psychiatric and Low Secure Units


AIMS Accreditation Committee (Royal College of Psychiatrists CCQI)

Andrew Dean None specified

Dan Meron None specified

Tim Williams None specified

The Register of Interests is maintained by the Company Secretary. It is annually reviewed by the Trust Board and is made publicly available on request.

Fit and Proper Persons Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 5 created a new requirement for all Directors of NHS organisations must be confirmed as “fit and proper” as assessed against criteria defined within the Regulation.

The new Fit & Proper Persons requirement came into effect from November 2014. Executive Directors and Non-Executive Directors are required to certify on appointment and on an annual basis thereafter that they meet the requirements of the Fit & Proper Persons test.

All Trust Board members have declared that they meet the requirements of the Fit & Proper Persons test, and the Trust continues to develop its processes for ensuring that it remains compliant with this Regulation for both newly appointed and existing Directors.

Fraud The Trust Board is committed to maintaining an honest and open atmosphere within the Trust through minimising any fraud within the Trust and rigorous investigation of any such cases. Where any acts of fraud or corruption are proven, the Trust ensures


that these are appropriately dealt with, and takes steps to recover any losses in full.

The Trust’s reporting procedures are detailed in the Trust’s Counter Fraud Policy which is available on the Trust’s Intranet and external website. It is the Trust’s policy that an employee should not suffer detriment as a result of reporting reasonably held suspicions. Any reasonably held suspicions should normally be reported to the Local Counter Fraud Specialist (LCFS) or Executive Director of Resources. Serious concerns may also be raised using the Trust’s Public Interest Disclosure (Whistleblowing) Policy.

Reports on counter fraud activity are made available to the Audit and Risk Committee.

Cost allocation and charges for information The Trust has complied with cost allocation and charging requirements set out in the HM Treasury Guidelines.


Summary of serious incidents requiring investigations involving personal data as reported to the Information Commissioner’s Officer 2015/16

Date Nature of incident Nature of data involved

Number of data subjects potentially affected

Outcome

June 2015 Disclosed in error Email sent to wrong address

one Partner agency responsible for incident, support and advice provided

July 2015 Disclosed in error Letter sent to wrong address

one Team reminded of procedure

July 2015 Disclosed in error Letter mentioned incorrect first name only of a patient

one Full investigation via complaints

July 2015 Disclosed in error Letter sent to wrong One House number written down wrong, neighbour decided to open letter instead of returning to the return address on the envelope or giving to rightful addressee

July 2015 Other Email sent insecurely One Partner agency responsible for incident, support and advice provided

August 2015 Disclosed in error Letter sent to wrong address

One Address had not been updated on the spine


One NHS number not used as the unique patient identifier, team reminded of procedure

August 2015 Disclosed in error Wrong address written on prescription

One Investigation established human error


One Address had not been updated on the spine

September 2015

Disclosed in error Letter sent to wrong address

One Patient gave wrong address

September 2015

Disclosed in error Email sent to wrong address

One Partner agency responsible for incident, support and advice provided

October 2015

Other Personal information found by staff in hospital care park

Three Identified that service user had dropped the


information

October 2015

Other Email sent insecurely One Team reminded of correct procedure

October 2015

Disclosed in error Personal information recorded on wrong patients’ record

One NHS number not used as the unique patient identifier, team reminded of procedure

November 2015

Disclosed in error Email sent to wrong address

One Team reminded of correct procedure

November 2015

Unauthorised access/disclosure

Allegation of breach of patient confidentiality

One Agency staff – agency advised and that staff member could no longer work for the Trust and team reminded of confidentiality duties

The Trust will continue to monitor and assess its information risks, in light of the events noted above, in order to identify and address any weaknesses and ensure continuous improvement of its systems.

Staff involved in the above incidents were dealt with in accordance with Trust disciplinary policies and procedures as appropriate

Summary of other personal data related incidents in 2015/16

Category Breach type Total

A Corruption or inability to recover electronic data 0

B Disclosed in error 12

C Lost in transit 0

D Lost or stolen hardware 0

E Lost or stolen paperwork 0

F Non-secure disposal – hardware 0

G Non-secure disposal – paperwork 0

H Uploaded to website in error O

I Technical security failing (including hacking) 0

J Unauthorised access/disclosure 1

K Other 3


Patient Advice and Liaison Service (PALS) Praise and Complaints The PALS service continues to provide free, confidential, impartial advice to service users, families, carers and interested members of the public. PALS help the Trust to know how people feel about our services and how they experience the care we deliver. The information gathered by the team acts as early warning system for the Trust when things are not right, and they help us to improve our services.

Learning from complaints

All complaints and concerns are treated as feedback and an opportunity to learn, develop and improve. The key purpose of our complaints and concerns handling process is to identify what, if anything, went wrong, to apologise, to describe the learning from the investigation and to set out clearly the action the Trust has taken to minimise the risk of it happening again. We had 360 formal complaints this year compared to 314 last and 1122 items of praise recorded compared to 724 last year.

Below is a breakdown of the total number of complaints by theme.

Overarching Themes

Responsive

Bed management 12

Cancelled 3

Choice 4

Delay 20

Discharge 24

Out of area 4

Referral 12

Service denied 10

Service not available 2

Transport 2

Total 93

Effective

Care coordination 6

Clinical care 63

Confidentiality 14

CPA 1

Diagnosis 7

MHA 8

Physical Health 3

S17 leave 5

Second opinion 1

Total 108

Caring

Attitude of staff 73

Communication 18

Discrimination 4

Information and advice 2

Privacy and dignity 2

Total 99

Safety

Activities 1

Medication 17

Personal property 4

Physical intervention 4

Safeguarding/ Vulnerable adult

5

Safety (personal) 7

Total 38

Well Led

Administration 1

Health records 12

Patient information 1

Policy/ procedure 3

Requests for information 2

Staffing levels 3

Total 22

Actions arising from complaints can range from system issues or policy changes to

Complaint Theme No’ of complaints

Responsive 93

Effective 108

Caring 99

Safety 38

Well Led 22

Total 360


arranging an appointment for someone to review their care. Each action is tracked to ensure completion and they are recorded on a plan which is monitored and has senior management oversight.

Getting it right

This year the Trust has implemented an on-line praise recording so teams can let us know when they have received a compliment about their service. These are then received by the PALS team and reviewed so we can see what is being praised and we can look at areas of good practice. This year has seen compliments rise from 724 to 1122.

We also want to get it right when we receive a complaint. When the government published Hard Truths, its response to the Francis Enquiry, the Parliamentary Health Service Ombudsman, Local Government Ombudsman and Healthwatch carried out an extensive consultation of users of the NHS and Social Care complaints system and committed to developing a user-led ‘vision’ of the complaints system. The outcome of this has produced a comprehensive guide to what good outcomes for service users and carers looks like if complaints are handled well. This is called ‘My expectations for raising concerns and complaints.’ They defined a good complaint journey taking it from the initial consideration into making a complaint, to communication with staff and institutions, and finally final reflection on the experience. A good complaint journey is summed up in their document as: “I felt confident to speak up and making my complaint was simple. I felt listened to and understood. I felt that my complaint made a difference”. Following this publication, the Trust redesigned its complaints survey and this is sent to everyone who completes a complaint process. We can then see where improvements are required and the Trust can develop its systems. The results of the surveys are shared with staff to support them in how to manage complaints well and compassionately.

Principles for Remedy

The complaints service is an operational service subject to national legislation (The Local Authority Social Services and National Health Service Complaints (England) Regulations, 2009) and related guidance. It must also operate within prescribed national standards laid down regulation 9 of the Health and Social Care Act 2008 Registration Requirements 2009, related Care Quality Commission guidance to Quality and Safety Outcome 17 on Complaints, the NHS Constitution, and in line with the Parliamentary Health Service Ombudsman’s Principles for Remedy.

Health and safety The Trust has continued its focus on patient safety and environment throughout 2015 with work progressing on standardising fixtures and fittings and improving the way we test and evaluate new fixtures and furniture.

The Trust continues to invest time, energy and funding into improving ligature reduction technology into our wards with a clear strategy for continued improvements next year. This has included keeping a close watch on emerging technology and working collaboratively with suppliers including development of new products for mental health wards.

The Trust also continues to work towards smoking reduction with two wards currently piloting smoke free environments. The Trust has an interest group liaising with colleagues in Public Health to address the health issues and equality concerns that smoking has disproportionally with people who use mental health services.

A key staff safety initiative has been the introduction of safer sharps, to prevent needle stick injuries. This has been backed up with systems to inform and monitor sharps use.

Improvements have been made to the way the Trust monitors risk assessments and continues to be supported with auditing


systems that feedback information and assurance.

Fire safety management systems have had a major overhaul and these have seen improvements in the way risks are managed and give the Trust a greater level of detailed information on risks. This has resulted in lower risks and more complete compliance with fire safety legislation.

Resilience The Trust continues to place significant focus and effort into ensuring that, as a minimum, we remain fully compliant with the requirements of the NHS Emergency Preparedness Framework 2015 and the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 2015. This enables us to comply with the duties placed upon us by the Civil Contingencies Act 2004, the Health and Social Care Act 2012 and the NHS Standard Contract.

Compliance is monitored through peer review and annual Emergency Preparedness, Resilience and Response audits conducted by NHS England Area Teams and North Somerset Clinical Commissioning Group (CCG) and we have this year been assessed as ‘substantially compliant’. The CCG added that this compliance rating does not truly reflect the Trust’s EPRR arrangements, which are some of the strongest in the LHRP. In addition, the CCG acknowledged that the 2014 assurance process had already highlighted our use of technology to support on-call staff and business continuity arrangements and that this programme had now been further developed and is now embedded in business as usual practices and used by managers to report incidents/ issues on a daily basis. Our sleeping contract with a call centre provider was also highlighted as an area of best practice.

This focus and effort ensures that, in times of operational challenges, for example during severe weather, fuel supply problems or industrial action, the Trust is capable of delivering its core critical services. We continue to work closely with other

providers of NHS funded care to enhance resilience and are active members of two Local Health Resilience Partnerships (LHRPs) at both Strategic and Tactical levels. This enables us to collaborate with and support our local health communities, thereby influencing and improving system wide resilience.

Business Continuity also continues to be enhanced at both a Trust and Locality (service delivery) level and we continue to be compliant with the International Standard for Business Continuity ISO22301. All Service Delivery Units have robust Service Continuity Plans in place and Directorate Service Continuity Plans are also now in place. We have recently conducted a series of Service Continuity exercises at Locality level to test the plans and enable relevant staff to become familiar with their roles during disruption, and an exercise to test the new Directorate Service Continuity Plans is scheduled for April 2016. Additionally, key personnel have undertaken internal and external training to further increase knowledge and capability. Core Standard 34, relating to training, was confirmed as ‘amber’ due to the number of managers awaiting Strategic Leadership in a Crisis (SLC) Training. As both our LHRPs had put a hold on SLC training, awaiting a regional package, the Trust independently arranged an internal course for January 2016 and, consequently, all our On-Call Executive Directors have now attended this training and, therefore, this Core Standard should now be confirmed as ‘green’.

Financial Statements


Statement of the Chief Executive's Responsibilities as the Accountable Officer of the Trust The Chief Executive of the NHS Trust Development Authority has designated that the Chief Executive should be the Accountable Officer to the trust. The relevant responsibilities of Accountable Officers are set out in the Accountable Officers Memorandum issued by the Chief Executive of the NHS Trust Development Authority. These include ensuring that: - there are effective management systems in place to safeguard public funds and assets and assist in the implementation of corporate governance; - value for money is achieved from the resources available to the trust; - the expenditure and income of the trust has been applied to the purposes intended by Parliament and conform to the authorities which govern them; - effective and sound financial management systems are in place; and - annual statutory accounts are prepared in a format directed by the Secretary of State with the approval of the Treasury to give a true and fair view of the state of affairs as at the end of the financial year and the income and expenditure, recognised gains and losses and cash flows for the year.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my letter of appointment as an Accountable Officer. I confirm that, as far as I am aware, there is no relevant audit information of which the trust’s auditors are unaware, and I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the trust’s auditors are aware of that information. I confirm that the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable.

Signed



Statement of Directors' Responsibilities in Respect of the Accounts The directors are required under the National Health Service Act 2006 to prepare accounts for each financial year. The Secretary of State, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the trust and of the income and expenditure, recognised gains and losses and cash flows for the year. In preparing those accounts, directors are required to:

- apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury;

- make judgements and estimates which are reasonable and prudent;

- state whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts.

The directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts

By order of the Board

Signed

Chief Executive

25 May 2016

Signed

Director of Resources

25th May 2016

Parliamentary Accountability and Audit Report


The Trust is reporting a full year surplus of £90k which is a small improvement on the break-even position agreed with the TDA in February 2016. The original planned surplus for the year was £2.03m, but the financial impact of ongoing difficulties in staff recruitment has impeded the ability to deliver the planned surplus.

The retained surplus excludes impairments which are technical in nature and are exceptional items. A reconciliation of these amounts can be found in the Income and Expenditure Account (Page 1 of the accounts)

A cash balance of £5.6m at the year-end achieved the planned balance of £5.6m.

The Financial Risk Rating is reported as a 3 which is in line with the plan and this is made up of liquidity ratio of 4 and debt servicing ratio of 2. The score of 2 on the debt servicing ratio is due to the Trust having PFI financing obligations.

2015/16 has proved a financially challenging year due primarily to the requirements of safer staffing and on-going recruitment difficulties for both medical and nursing staff.

Key financial performance indicators Under the metric framework, the weighting of the liquidity ratio and capital servicing capacity have been reduced from 50% to 25% and two new measures both weighted at 25% have been added. These are the Income and expenditure (I&E) margin and Variance from plan in relation to I&E margin. The former is the degree to which the organisation is operating a surplus/deficit

and the latter is the difference between the planned and actual I&E margin

CSR and financial efficiency is Monitor’s rating score of 1(lowest) and 4 (highest), the Trust has achieved a 2 for the year

Income Operating income received in 2015/16 by the Trust was £197.4m, with £187.9m (95%) coming from the delivery of patient care services. The largest proportion of the Trust’s clinical income comes from its main six CCGs. Non-clinical income for the period is £9.5m with the majority of this income received to fund education, training and research. A breakdown of total income by source is shown in the graph below:

Expenditure Operating expenses totalled £188.2m for the year and, as in previous years, staff costs including Board members account for the largest use of resources at 77% of the total expenditure.

An analysis of operating expenditure by type is shown in the graph below.

2015/16 MetricWeight

ingRating Score

Balance Sheet

sustainability25% 1.6 times 2

Liquidity 25% 11 days 2

Underlying

Performance

I&E Margin

25% 0.00% 2

Variance from

Plan25% -1.04% 2

2

Continuity

of Service

Financial

efficiency

Sustainability and Financial Performance Risk Rating

NHS Trusts

NHS England

CCGs

Foundation Trusts

Local Authorities

Education, training,research


Capital Programme Capital Expenditure for the year is £11.12m which is higher than would normally be the case, due to the capital costs of the Intensive Support Unit in Wiltshire, amounting to around £1.5m, work on the re-provision of inpatient services in Bath for £2.4m and urgent CQC work. There are disposals to the value of £1.0m which meant that the Capital programme came within the Capital Resource Limit (CRL).

The chart below sets out the capital split of projects.

Balance Sheet Events In the opinion of the Board of the Trust, there are no post balance sheet events

Going Concern After submission of the latest operating plan and forecasts, and after making enquiries, the directors have a reasonable expectation that the NHS trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.

Pay costs

Services from NHS

Services from Non-NHS

Supplies

Consultancy

Establishment

Transport

PFI operating costs

Premises

Legal

Depreciation &impairments

R&D, Education, training

Other

CQC Works

IT

Buildings

Lifecycle works

Wiltshire ITU

Other

Parliamentary Accountability and Audit Report


Independent Auditor’s Report to the Directors of Avon and Wiltshire Mental Health Partnership NHS Trust - Draft We have audited the financial statements of Avon and Wiltshire Mental Health Partnership NHS Trust for the year ended 31 March 2016 under the Local Audit and Accountability Act 2014. The financial statements comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Changes in Taxpayers’ Equity, the Statement of Cash Flows and the related notes. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the 2015/16 Government Financial Reporting Manual (the 2015/16 FReM) as contained in the Department of Health Group Manual for Accounts 2015/16 (the 2015/16 MfA) and the Accounts Direction issued by the Secretary of State with the approval of HM Treasury as relevant to the National Health Service in England (the Accounts Direction). We have also audited the information in the Remuneration and Staff Report that is subject to audit, being:

the table of salaries and allowances of senior managers and related narrative notes on page 20;

the table of pension benefits of senior managers and related narrative notes on page 21; narrative notes relating to exit packages on page 23; the analysis of staff numbers on page 22; and narrative notes relating to pay multiples on page 23.

This report is made solely to the Directors of Avon and Wiltshire Mental Health Partnership NHS Trust, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014 and as set out in paragraph 43 of the Statement of Responsibilities of Auditors and Audited Bodies published by Public Sector Audit Appointments Limited. Our audit work has been undertaken so that we might state to the Directors of the Trust those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Trust and the Trust's Directors, as a body, for our audit work, for this report, or for the opinions we have formed.

Respective responsibilities of Directors and auditor As explained more fully in the Statement of Directors’ Responsibilities, the Directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.

As explained in the statement of the Chief Executive's responsibilities, as the Accountable Officer of the Trust, the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the Trust's resources. We are required under Section 21(3)(c) and Schedule 13 paragraph 10(a) of the Local Audit and Accountability Act 2014 (the "Act") to be satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report our opinion as required by Section 21(4)(b) of the Act.

We are not required to consider, nor have we considered, whether all aspects of the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.


Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of whether the accounting policies are appropriate to the Trust’s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Directors; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.

Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2015, as to whether the Trust had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2016. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

Opinion on financial statements In our opinion the financial statements:

give a true and fair view of the financial position of Avon and Wiltshire Mental Health Partnership NHS Trust as at 31 March 2016 and of its expenditure and income for the year then ended; and

have been prepared properly in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the 2015/16 FReM as contained in the 2015/16 MfA and the Accounts Direction.

Opinion on other matters In our opinion:

the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the 2015/16 FReM as contained in the 2015/16 MfA and the Accounts Direction; and

the other information published together with the audited financial statements in the annual report and accounts is consistent with the financial statements.


Matters on which we are required to report by exception We are required to report to you if:

in our opinion the governance statement does not comply with guidance issued by the NHS Trust Development Authority; or

we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the Trust, or an officer of the Trust, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or

we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or

we make a written recommendation to the Trust under section 24 of the Local Audit and Accountability Act 2014; or

we are not satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2016.

We have nothing to report in these respects.

Certificate

We certify that we have completed the audit of the accounts of Avon and Wiltshire Mental Health Partnership NHS Trust in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice. Barrie Morris for and on behalf of Grant Thornton UK LLP, Appointed Auditor Hartwell House 55 – 61 Victoria Street Bristol BS1 6FT May 2016


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