meeting of the trust board . 1.00pm, thursday, 2nd february 2018 . conference room 1, trafalgar...

PUBLIC MEETING OF THE TRUST BOARD

1.00pm, Thursday, 2nd February 2018

Conference Room 1, Trafalgar House, Dudley AGENDA

Culture and Conduct Protocol

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

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

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

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

ITEM Purpose Board Lead Format Timings

1. EBE Reflection Assurance Mr Axcell Oral 1.00pm

2. Apologies Mr Turner Oral 1.30pm

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

Mr Turner Oral

4.

Minutes of the Previous Meeting To approve the minutes of the Board meeting held on 11 January 2018

Approval Mr Turner Enc 1

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

6. Summary Report of Confidential session of Trust Board held on 11 January 2018 Information Mr Turner Enc 3

7.

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

Information

Mr Axcell

Enc 4 1.35pm

8. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

8.1 Trust Integrated Performance Dashboard (Month 9) including the Performance Dashboard and Contract Performance Report Dashboard

Assurance

Mr Davies Enc 5 1.45pm

8.1.1 a b c d

Quality Quality & Safety Committee Chair’s Report from meeting held on 10 January 2018. Quality & Safety Committee Minutes from meeting held on 13 December 2017 Mental Health Act Scrutiny Committee Draft minutes from the meeting held on 14 December 2017 Quality Report

Assurance Assurance Assurance Assurance

Dr Murphy Dr Murphy Mr Burbeck Mrs Musson

Enc 6 Enc 7 Enc 8 Enc 9

1.50pm


8.1.2 a b c d

Finance & Performance Finance & Performance Chair’s Report from meeting held on 22 January 2018 Finance & Performance Committee Minutes from meeting held on 18 December 2017 Finance Report Cost Improvement Programme (CIP) Progress Report

Assurance Assurance Assurance Assurance

Mr Turner Mr Turner Mr Davies Mr Davies

Enc 10 Enc 11 Enc 12 Enc 13

2.10pm

8.1.3 a b c

Workforce Workforce Committee Chair’s Report from meeting held on 23 January 2018 Workforce Committee Minutes from meeting held on 19 December 2017 Workforce Performance Report

Assurance Assurance Assurance

Mr Turner Mr Turner Mrs Williams

Enc 14 Enc 15 Enc 16

2.30pm

8.2 Medical Directors’ Report

Assurance Dr Weaver Enc 17 2.45pm

8.3 Director of Nursing Report

Assurance Ms Musson Enc 18 2.50pm

8.4 Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Assurance Ms Musson Enc 19 2.55pm

8.5 Director of Operations Report Assurance Mrs Writtle Enc 20 3.00pm

8.6 High Level Operational Risk Register Assurance Mrs Musson Enc 21 3.05pm

9. STRATEGIC DEVELOPMENT & DIRECTION

9.1 Annual Plan 2017/18 – Quarter 3 Review Assurance Mr Axcell To Follow

Enc 22 To follow

3.10pm

9.2 Board Assurance Framework (BAF) – Quarter 3 2017/18

Assurance Mr Lewis-Grundy

Enc 23 3.15pm

10. LEADERSHIP, CULTURE AND WORKFORCE

10.1 Communications & Engagement Quarterly Dashboard – Quarter 3

Assurance Mr Axcell Enc 24 3.20pm

11. FOR ASSURANCE

11.1 MERIT Vanguard Overview Report Assurance Mr Axcell Enc 25 3.30pm

11.2 MExT Chair’s Report from the meeting held on 23 January 2018.

Assurance Mr Axcell Enc 26 3.35pm

11.3 Committee Membership – Non-Executive Director Review – February 2018

Assurance Mr Lewis-Grundy

Enc 27 3.40pm

11.4 Trust Board and Committee Schedule 2018/19 Assurance Mr Lewis-Grundy

Enc 28 3.45pm


12. ANY OTHER BUSINESS 3.50pm

13. QUESTIONS FROM MEMBERS OF THE PUBLIC

Questions from members of the public pertaining to agenda items.

Oral

14. DATE AND TIME OF THE NEXT MEETING

Thursday 1st March 2018 at 1.00pm in The Boardroom, Canalside, Bloxwich, Walsall.

Enc 1 MINUTES OF THE TRUST BOARD MEETING OF

DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST

Held at 2.30pm on Thursday, 11 January 2018 The Board Room, Canalside, Bloxwich

PUBLIC SESSION Present Mr B Reid Chair Mr M Axcell Chief Executive Officer Mr J Burbeck Associate Non-Executive Director Mr R Davies Interim Director of Finance, Performance and IM&T Dr K Gingell Joint Medical Director Mr J Lancaster Non-Executive Director Dr S Murphy Non-Executive Director Mrs R Musson Acting Director of Nursing Mr P Rana Non-Executive Director Mr H Turner Non-Executive Director Dr M Weaver Joint Medical Director Mrs L Writtle Interim Director of Operations In Attendance Mr P Lewis-Grundy Company Secretary Mrs L Wix Acting PA to Chief Executive/Chair/Non-Executive

Directors (minutes) ITEM ACTION 191. APOLOGIES & WELCOME

Apologies had been received from Mrs A Williams, Acting Director of People

192. DECLARATIONS OF INTEREST

Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. Dr Murphy reminded the meeting that he was also a Non-Executive Director at Birmingham Community Healthcare NHS Foundation Trust. Mrs Writtle declared an interest being the Director of Operations at Black Country Partnership Foundation Trust

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as well as interim Director of Operations at Dudley & Walsall Mental Health NHS Trust. There were no other interests declared in addition to those already recorded on the Register of Interests.

193. MINUTES OF THE PREVIOUS MEETING

To approve the minutes of the meeting held on 7th December 2017. RESOLVED: That the minutes of the meeting held on 7th December 2017 be approved and signed by the Chair.

194. MATTERS ARISING/ACTION SCHEDULE

Minute….. Dr Murphy queried whether the Trust had been fined in relation to the Instant Access to Psychological Therapies IAPT) underperformance. Mrs Writtle advised that a fine had not been imposed to date although this remained a risk going forward. Minute 186.2 Service Experience Desk Report Q2 – CAMHS waiting times Mrs Writtle advised that in Walsall patients were seen once they had been referred, and the waiting time in Dudley was 16 weeks. The disparity was due to the differing levels of funding from the CCGs. Action completed. Closed. All other items were either complete or had a future completion date. RESOLVED: That the matters arising and the assurance given where those actions have been completed be noted.

195. SUMMARY REPORT OF THE CONFIDENTIAL SESSION OF TRUST BOARD HELD ON 5th OCTBER 2017.

Members noted the content of the confidential summary of the meeting held on 7th December 2017. RESOLVED: That the Board received the report for information.

196. CHIEF EXECUTIVE OFFICER’S OVERVIEW

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The Chief Executive presented his report and gave an update on the following: Transforming Care Together – The TCT partnership continued to progress and discussions were currently ongoing on next steps to ensure all aspects of further work required were addressed in an appropriate manner. A draft plan had been developed and NHSI had formally responded. Communications related to the TCT were expected to be issued over the coming weeks.

MERIT Vanguard – The MERIT Vanguard continued to make excellent progress in shaping crisis and recovery services across the West Midlands. The shared record system had gone live. The four Trusts were sharing bed information on a regular basis to support the appropriate placement of service users as close to home as possible avoiding out of area placements. The Training passport which enabled staff to move more easily between the four Trusts by taking their mandatory training with them was up and running.

At the meeting in December attended by the four Trusts, agreement had been reached to continue to develop the currently agreed priorities and initiatives. Funding would cease at the end of March 2018 and a paper drafted to identify those initiatives that would continue post April 2018 would be submitted to the four Trust Boards.

Mr Rana joined the meeting at 2.33pm.

Mr Hirons provided the Freedom to Speak Up quarterly update.

He advised that since the last report one new incident had been raised with the Freedom to Speak Up Guardian (FTSUG) – this had been received via HR and related to a known, reported incident already under investigation,

Two of the three concerns raised in quarter two were still open, and regular feedback on progress has been provided via the guardian.

TCT meetings between the three Trusts respective guardians will resume in 2018. The next National Guardians conference would be held on 6th March and regional meetings were ongoing.

The FTSUG had undertaken a series of visits to Ward meetings in his capacity in this role and Engagement Lead to continue the process of making the role more visible and reassuring staff.

The Chair queried whether the three partnership Trusts had similar issues raised by staff and Mr Hirons confirmed this to

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be the case which mainly related to cultural behaviour, management and staff issues. Mr Hirons remarked that generally the Guardian role had developed in ways that had not been originally envisaged with a greater emphasis on culture and behaviour in the Trust and this was reflected nationally. Staff had expressed concerns about raising issues as they were unsure how this would impact on working relationships with colleagues and the process was prolonged causing anxiety and stress to individuals. Mrs Writtle advised that she had been involved in the cases of two individuals who had raised concerns and had discussed with them attending a Board meeting to talk about their experience. In order to encourage individuals to raise concerns it was suggested that they be treated in a similar way to the “Moment of Truth” initiative and that staff who raise concerns be thanked for so doing. These would be reviewed by the Workforce Committee.

ACTION: Workforce Committee to review the suggestions for encouraging individuals to raise concerns.

Mr M Hirons left the meeting.

Mr Axcell advised that he would also like to put on record his thanks to staff during the severe weather experienced in December. Many staff went ‘the extra mile’ to ensure that the Trust could continue to deliver patient care. He commended those staff members who had walked many miles in the snow to work or had undertaken double shifts to ensure continuity of care.

The Chair queried whether any action had been taken to improve the position in relation to the estates function. Mr Davies confirmed that there was already an improving position since the Trust had been working in conjunction with Birmingham Community Healthcare Trust’s (BCHC) Estates Department.

The Chair asked for an update on the Bloxwich site and Mr Davies reminded members that the Outline Business Case had been received by members in late 2017 and he anticipated that the Full Business Case would be presented to the Board in March 2018.

Mr Axcell advised that this would be Dr Gingell’s last Board meeting as she was standing down as Joint Medical Director at the end of the month. He commended Dr Gingell for her leadership, innovation and the positive impact she had had in the Dudley area and on the progress of the Dudley MCP and TCT Integration. The positive work with GPs developing Multi-Disciplinary Teamswas also due to Dr Gingell’s leadership skills. Dr Gingell thanked the Board and said that she had learnt a lot from colleagues in her Joint Medical

Mrs Williams

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Director role and that whilst she was returning to clinical and teaching duties she would continue to offer the Trust support however she could. RESOLVED: That the Board

• Noted the information and actions contained within the report.

197. Feedback from OnBoard visits - 11 January 2018

Home Treatment Team Dr Murphy and Mrs Writtle had visited the team and had been impressed by the enthusiasm demonstrated by members. The following was noted:

• The team had several suggestions for improving the service, including working with medical colleagues on changes to service models.

• The team were involved in bed management, Section 136 Suite and Mrs Writtle would review this to identify whether this could be better managed elsewhere.

• Increased acuity/activity and capacity issues were raised.

• There was an underlying culture that managers needed permission to initiate changes and the team may need support to encourage them to work differently.

• The team put forward the view that the organisation was risk averse with individuals held to account should things go wrong.

• The team expressed an ambition to upskill staff and to be proactive rather than reactive.

• The team highlighted the intention to seek accreditation.

• Concerns were expressed relating to the TCT Partnership and how this would impact on their day jobs.

• A number of estates issues and issues about the working environment were raised which would be reviewed by the Interim Director of Operations.

Mr Axcell advised that teams should be encouraged to be innovative and be supported in implementing new ways of working. Mrs Musson and Mrs Writtle advised that they had similar conversations with other teams in relation to the implementation of new ideas. Mr Axcell advised that the Executive Team would consider

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ways in which innovation across the Trust could be supported. ACTION: Executive team to consider ways in which innovation across the Trust could be supported. . Therapeutic Hub, Bloxwich Mr Lancaster advised that the Hub had only recently moved to the Bloxwich site. Concerns were expressed by the team regarding the suitability of the physical environment and given the profile of the service users whether it was appropriate to be ased on a site tha cared for older adults. There was a sence that the client group that would bebenfit from these services would rather access them from a non-NHS branded building embedded in the community.The other themes discussed with the team were similar to those raised by the Home Treatment Team. Adult Community Recovery Service, Mossley Day Hospital Mr Burbeck advised that the Adult Community Recovery Service team was experienced, well established and worked well. The main area for concern was the impending dissolution of the Section 75 Agreement in Walsall which would mean that social workers would work independently of the team in a local authority setting and this would have a significant impact on service users, team. The Chair queried whether the Trust has strenuously resisted the dissolution of the Section 75 Agreement and Mr Axcell confirmed this to be the case and that having met recently with the newly appointed Chief Executive of Walsall Council it was unlikely that the decision would be reversed. Mrs Writtle advised that Task and Finish groups were set up to make the transition as smooth as possible. Mr Burbeck also highlighted the discussion he had with the team about the transition of patients from CAMHS into adult mental health services and the improvements that should be made to support patients. RESOLVED: That the Board noted the verbal updates information and assurance and how any agreed actions would be progressed.

Exec Team

198 QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

198.1 Trust Integrated performance Dashboard & Contract Performance (Month 8)

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Mr Davies presented the report advising that it made reference to performance across the four domains of, Quality and Safety, Service User Experience, Efficiency and Resources and referred specifically to:

• A reduction in the number of incidents in month 8, although early indications were that there had been an increase in month 9.

• Two serious incidents which had been reported. • The Trust’s good performance against CPA targets. • The strong performance across all the Trust’s

performance indicators highlighted through the dashboard, with ten being amber rated, the remainder green and no red RAG rated indicators.

RESOLVED:

That the Board noted the content of the report.

198.2 Quality & Safety Committee Chair’s Report

In presenting his report, Dr Murphy drew attention to the following: TCT The Committee had discussed at length the implications of the TCT pause for the quality and safety of services. This discussion encompassed the agenda items on the Risk Register and the Board Assurance Framework. Door Top Pressure Sensors The Committee received assurances that there were local processes in place on Ambleside to manage the interim situation regarding door top pressure sensors. The Committee noted the progress made and would receive a full update in April 2018 Deep Dive – Kinver Ward The Committee received a deep dive report which looked at the spike of incidents on Kinver Ward. The spike predominantly related to one patient. In terms of learning lessons the Committee discussed the use of early warning indicators. This would be explored further and proposals presented to a future Committee meeting. Quality and Safety Report The Quality Report was presented to the Committee for information and assurance. A total of 441 incidents were reported during November and this represented a decrease of 17% compared to October.

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It was noted that there had been eight Serious Incidents reported in December including incidents of suicide and of serious self-harm with a high proportion being linked to Dudley Talking Therapies. The Committee would review these to identify whether there were specific issues within that service. The Chair reported the increased suicide risk in January and whilst staff were trained in suicide prevention and awareness further communication would be provide to teams to remain alert to this risk. ACTION: Communication provided to teams to remain alert to the increased risk of patient suicide in January. Annual Anti-Ligature Assessment Review The Committee received assurance that the annual anti-ligature assessment had been completed for all 9 inpatient wards in line with Trust Policy. Quality and Safety High Level Risk Register The Committee reviewed the risk register. In addition a full discussion took place regarding the Trust’s current estates provision and the impact this may be having upon the quality of services. The Committee would review the Estates delivery plan in February. Dr Murphy commended BCHC colleagues for their support in relation to the estates function. The Committee noted the current position relating to high level risks and the further action being taken for inclusion of TCT risks. Dr Murphy advised that the fire risk would be downgraded from red to amber once the fire doors had been fitted, following which the Fire Services would be invited to undertake a fire safety audit. Board Assurance Framework (BAF) The Committee reviewed:

• Strategic Risk SR3 – Achieving Quality of Care

• Strategic Risk SR5 – Management, Maintenance and Strategy for the Estates

The Committee discussed the strategic risks in detail which had been updated and this was a separate Trust Board agenda item. Dr Murphy advised that he had received positive feedback from service users and Experts by Experience (EBEs) related to TMS. Dr Weaver advised that the pilot had been very successful and the business case would be submitted to MExT at the end of January to expand the service and this would realise financial benefits in the long term as patients mental wellbeing improved and they would not need to

Mrs Musson

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access other services. RESOLVED:

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

198.3 Quality & Safety Committee Minutes from the meeting held on 8 November 2017.

The Chair of the Committee presented the ratified minutes of the meeting held on 8 November 2017 for information.

198.4 Mental Health Act Scrutiny Committee Chair’s Report

In presenting the report, Mr Burbeck outlined the discussions outlined in the report and asked the Board to note that the Committee had received significant assurance on compliance with Mental Health Act requirements and that action was being taken to look at incident and intervention levels and harm indicators to identify a systematic way of conducting deep dives The Committee discussed the rgent actions were required to ensure the Trust could deliver the changes of service arising from amendments to the Police and Crime Act 2017/Section 135 and 136 of the Mental Health Act. Whilst Mrs Writtle confirmed that this was being addressed, Mr Burbeck reiterated that the Trust was not a progressing the actions at the pace needed and this would impact on the level of service that patients received under the Act. Mr Burbeck advised that the risk register was being reviewed to reflect the impact of TCT a joint meeting with the ALMS would be taking place in February and additional action was being taken to ensure training targets are being met.

RESOLVED:

That the Board accepted the report for assurance about the exercise of delegated authority by the Mental Health Act Scrutiny Committee.

198.5 Quality Report

Mrs Musson presented the Quality report for month 8 which made reference to:

• A summary of incidents • Operational Service Line Reports • Safety Alert Broadcasts (SABs) • Safeguarding Performance Framework

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She confirmed that the report had been reviewed by Quality & Safety Committee and referred to in the Committee Chair’s report.

RESOLVED:

That the Board received the report for information and assurance.

198.6 Finance & Performance Committee Chair’s Report

In presenting the report Mr Lancaster referred to the following: Performance

The following areas were noted:

• Activity continued to perform above the contracted levels (Month 8 at 6%).

• There was under-performance against 5 of the agreed 27 KPI’s;

o DWROM for Dudley (red RAG rated) o Number of patients receiving IAPT therapy (in

both Dudley & Walsall – both amber RAG rated)

o Percentage of service users (adult Mental Health) on CPA who were followed up within 7 days of discharge (Dudley target of 95%, actual of 93.2%)

o Percentage of service users provided with a copy of their care plan (Walsall target of 95%, actual of 94.7%)

o IAPT proportion of service users completing treatment moving to recovery (Walsall target of 50%, actual of 46.9%

• Delayed Transfer of Care – currently 3.9% compared to 4.2% last month and 6.4% the month before

• Readmissions – currently 11.8% compared to 13.2% last month and 5.7% the month before.

PbR & Clustering Report

The report was tabled and accepted – the Committee acknowledged the improving position and the progress made recently.

Finance Report & Income/Activity Report

The financial position to the end of November 2017 showed a £1,312k surplus which was £53k ahead of the plan (based on the planned annual surplus of £1,839k).

In November Contracted Income reflected an adverse

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variance of £14k. This had been driven in the main by the shortfall in Detox bed use (£64k behind plan). Income overall was in surplus by £122k which was being driven by education and training income, offsetting the adverse contracted income position mentioned above.

It was noted that combined CCG contracts were over-performing in activity terms, most notably within Walsall (£604k notional value), Dudley CCG (£311k notional value) and Sandwell CCG (£210k notional value) contracts, however, the block contract agreement means that the Trust was not paid for this activity.

Agency spend was discussed in light of the NHSI agency cap of £4.05m. The position year to date as of month 8 was reporting an underspend of £107k and had been good progress so far during the financial year. Overall pay spending was in surplus and was continuing to follow the trend of underspends as experienced throughout the previous financial year.

CIP performance reflected a delivery of £3.248m against the £3.8m target for the year.

Forecast outturn had shown a further improvement over last month coming down from an anticipated variance to target of £120k to just over £75k RESOLVED: That the Board received the report for assurance and information and noted the content and endorsed the decisions taken by the Finance & Performance Committee.

197.6 Finance & Performance Committee Minutes from the meeting held on 27 November 2017.

The Chair of the Committee presented the ratified minutes of the meeting for information.

RESOLVED:

That the Board received the minutes for information and assurance.

197.7 Finance Report

Mr Davies presented the report advising that the pertinent points had been covered comprehensively in the Finance & Performance Committee Chair’s Report.

RESOLVED: That the Board received the report for assurance and

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noted the content.

197.8 Cost Improvement Programme (CIP) Progress Report

In presenting the report, Mr Davies advised that 21 schemes had been identified in 2017/18 to achieve the CIP target of £3,778,000. Of these 21 schemes, 7 schemes had delivered, 9 schemes would deliver their PYE, 2 schemes had been closed without delivery and the remaining 3 schemes will not deliver the expected part year savings.

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

197.9 Workforce Committee Chair’s Report

In presenting the report Mr Turner highlighted the key messages:

Workforce Performance Report Month 8 Key messages from the Workforce Performance Month 8 Report were:

- Vacancies – There were currently 97 Full Time Equivalent contracted vacancies across the Trust meaning the vacancy rate had remained the same at 8.9% in Month 8.

- Turnover – The 12 Month Turnover rate had increased from 12.68% to 12.81%. The percentage turnover rate, excluding junior medical staff was average compared with other mental health organisations in the NHS.

- Sickness Absence – The rolling 12 month sickness rate had increased to 3.98% in Month 8 from 3.88% in Month 7, this was within the Trusts target and the thirteenth consecutive month of being so.

- In month sickness had increased from 3.91% in Month 7 to 4.98% in Month 8 and this may have been influenced by the early payroll cut off for December.

- Appraisal – Compliance had reduced to 83.9% in Month 8 which was below the Trust target of 85%. 146 people need appraisal. The discussion focused on data quality and the accurate recording of completed appraisals.

- Mandatory Training - Mandatory Training compliance had reduced slightly to 89.4% in Month 8 and was just below the target of 90% agreed at MEXT for all mandatory training. This was disappointing

- Essential Skills Training compliance was 72.2%, which was below target but has been on an upwards trajectory from the last 12 months. From April 2018

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mandatory and essential training was to be combined and a detailed plan would be presented to the next Committee meeting on how to increase compliance.

Flu Campaign The Committee were informed that the Trust’s Flu vaccination rate as of 18 December 2017 was 63% for frontline/clinical workers. The CQUINN target is 70% by end of February 2018. Staff Survey An initial analysis of the draft embargoed 2017 Staff Survey results had been undertaken and the Committee was given a verbal update. The Trust had achieved a 52% response which was a slight increase from last year’s survey. The response rate was also the highest of the TCT partners. The results were positive overall with a number of improvements in several areas including appraisal, communications and resources at work. A full report and action plan would be presented to a future meeting the Committee. Workforce Planning Health Education England (HEE) had requested a submission regarding the STP’s Black Country Workforce Plan. The Trust had worked in partnership with Black Country Partnership NHS Foundation Trust to respond to HEE’s queries.. The Trust would be completing its annual workforce plan, a combined Mental Health workforce plan for Mental Health will be submitted to HEE ready for March 2018. Workforce Risk Register The Committee received the workforce risk register and the Committee was assured that the risks were being appropriately managed. The Risk Register had been reviewed and updated. Safe Staffing Levels The Committee received the Month 8 Safe Staffing report. No concerns had been raised regarding fill rates. Work would continue to ensure safe staffing levels are maintained on night shifts. A vacancy review had been completed for inpatients; the Trust faced challenges in relation to the recruitment of Band 5 nurses and there was a proactive recruitment campaign in place. Recent recruitment drives have been successful. This would continue to be monitored. RESOLVED: That the Board received the report of the meeting for

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assurance and information and noted the content.

197.10 Workforce Committee Minutes from the meeting held on 27 November 2017.

The Chair of the Committee presented the minutes of the meeting advising that they were for information.

RESOLVED:

That the Board received the minutes for information and assurance.

197.11 Workforce Performance Report

Mrs Williams presented the report, advising that the pertinent points had been covered comprehensively in the Workforce Committee Chair’s Report.

RESOLVED: That the Board noted the updates on key current workforce agenda items

198. Medical Directors’ Report

In presenting the Medical Directors report, Dr Gingell referred to the following:

The Consultation document “Supporting Research in the NHS” covering changes to simplify arrangements for research in the NHS and associated changes to the terms of the NHS Standard Contract” had been produced and the consultation finishes in February 2018. In addition “A Framework for Mental Health Research” had been produced with 10 recommendations for improving the state of mental health services through research. The recommendations recognising the life course and importance of prevention; the need for patient and public involvement; better co-ordination and investment in infrastructure; capacity building and the involvement of industry in research. Referring to the ‘Transforming children and young people’s mental health provision’ green paper, Dr Gingell advised that the Government had provided a significant amount of funding to CCGs with the express purpose of improving the mental health of children and young people, recognising the underfunding and inequality that had existed to date. The green paper continued this theme and set out an ambition for earlier intervention and prevention, a boost in support for the role played by schools and colleges, and better, faster access to NHS services

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The Trust continued to have successful recruitment to posts, with a full complement of Old Age Psychiatrists now employed in Dudley. Dr Gingell added that there had been a high calibre of shortlisted applicants for the vacant General Adult Psychiatrist post in Walsall and was hopeful that this would be appointed to.

Dr Gingell presented the Guardian of Safe Working report for assurance. Due to a change in role of the existing guardian Dr Gingell confirmed that a process would need to be followed to appoint a new guardian. RESOLVED: That the Board received the report for assurance and information and noted the content

199. Director of Nursing Report

In presenting the Director of Nursing Report, Mrs Musson gave Board an update on the following matters: Flu Update

The Trust was making progress regarding the uptake of Flu Vaccinations and continued to have a proactive vaccination campaign. Awareness was being raised with staff regarding the indicated Australian Flu epidemic to further attempt to reduce the impact.

Nurse staffing during difficult weather conditions

As referred to in the Chief Executive Officer’s report, there had been many accounts of staff making extra efforts to maintain service provision during the very difficult weather conditions. This included nurses walking significant distances to work, staying on site overnight, extending shifts and working flexibility to keep service running. Mrs Musson commended staff and was proud of the efforts made by the nursing staff and their ongoing commitment to the nursing 6 C’s to deliver high quality services. This was endorsed by the Board.

Delivering Quality Services during increased pressures

The Board was asked to note that during the festive period and with the increased winter pressures the NHS is currently facing, safer staffing levels had been maintained in inpatient areas during a period of increased pressure and activity.

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

200. Quality Improvement Priorities & CQUINN Quarterly

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Progress Report

In presenting the report, Mrs Musson advised that the report provided a quarterly update by exception on:

• Progress against Trust Quality Improvement Priorities 2017/18 • Progress against CQUINs 2017/18 • Identified risks and mitigations to delivery

The Trust continued to implement the Quality Improvement Strategy and promote a culture of ongoing quality improvement throughout the services delivered All Priorities and CQUINs had made progress in quarter two and where risks had been identified to the delivery the project leads had put mitigation plans in place. RESOLVED: That the Board noted the progress made in relation to Quarter 2 of the 2017/18 Quality Improvement Priorities and CQUINs and noted the reported exceptions.

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

In presenting her report Mrs Musson advised that the data represented November 2017 and the monthly trend analysis for a 12 month period. Across the inpatient areas the overall fill rates were 101.11%, with 97.66% for registered staff and 103.53% for care staff and this indicated the Trust was meeting the optimum level of fill rates. Typically where care staff rates exceed 100%, this was due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity. There was one ward to note as an exception, whereby the staff fill in part is within the lower category (Kinver Ward). An impact assessment had been completed that provided assurance safe staffing levels had not been compromised. Where staff had concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In November there were no incidents reported related to safer staffing in inpatient services. The Trust had in place a locally agreed standard of the minimum of 2 qualified members of staff per shift. Due to

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inpatient vacancies the Director of Nursing had sought further assurance that when the ward plans to drop below this standard, mitigations were in place to maintain patient safety. Assurance had been provided that full consideration was given to skill mix when using temporary staff especially on night shifts when this had resulted in one qualified member of staff being on duty with back up from the night coordinator as a qualified senior nurse and experienced HCAs. Assurance had been provided form Ward Managers that patient safety had not been compromised in changes in skill mix.

The Chair queried whether TCT partners’ reports were similar in content and Mrs Musson confirmed that a revised report which would align with TCT reporting would be submitted to the Board in February.

RESOLVED:

The Board: • Noted and discussed the monthly data return

submitted, that provided details of planned and actual staffing at ward level. Data represents November 2017 and a 12 month trend analysis.

202. Director of Operations Report

Mrs Writtle presented the report providing updates on the four service lines, Urgent & Access, Community, Early Intervention and Inpatients. Referring to the Instant Access to Psychological Therapies (IAPT) service, Mrs Writtle confirmed that the ‘Mental Health Strategies’ review had been completed in the autumn of 2017 and the Trust worked with both CCG’s to jointly plan and agree a way forward. Mrs Writtle confirmed that the Trust had received a performance notice however Improvements required not only internal work to transform services but also it relied on commissioners being clear about commissioning intentions, investment and support to train Trust staff to be compliant to deliver a nationally agreed model. Mrs Writtle confirmed that weekly meetings were being held to oversee and deliver a recovery plan to ensure rapid turnaround and development of this service.. Mrs Writtle advised that the Heads of Service were being supported recently appointed leads and this would impact positively on their operational input. Mrs Writtle confirmed that the Trust was experiencing a 96% occupancy rate and a deep dive would be undertaken by the Head of Inpatient Services to identify the reasons for the

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high rate. With reference to the dissolution of the Section 75 agreement in Walsall, the Trust continued to work closely with the Council through the task and finish groups to prepare for the dissolution in March 2018. The Council had appointed an interim Head of Service to ensure a phased transition of managerial duties back to the Council. A key piece of work was identifying whether patient’s needs were predominantly health or whether they meet the requirements of the Care Act and would therefore transfer with the Social Workers. The impact on the Trust’s community teams and on contracted activity levels was yet to be determined. RESOLVED: That the Board received the report for assurance and information and noted the content.

203. Trust Operational pressures Plan: Winter 2017/18

In presenting the report, Mrs Writtle advised that as part of NHS planning for potential operational pressures during Winter 2017-18, the Trust was required to demonstrate to NHS England and NHS Improvement that it had suitable arrangements in place to manage and mitigate the potential impacts of winter pressures. These must dovetail with and support those of local health and social care system partners and must be approved by the Board. The Operational Pressures Plan for Winter 2017-18 was the combined response of the Dudley and Walsall Mental Health Partnership NHS Trust and Black Country Partnership NHS Foundation Trust to the requirement to provide evidence of a suitable and proportionate response to potential operational pressures during Winter 2017-18. As such, it complimented and underpinned the associated Winter Plans of the A&E Delivery Boards within the Black Country area. RESOLVED: That the Board approved and ratified the Operational Pressures Plan for Winter 2017-18 in line with NHS England and NHS Improvement expectations

204. High Level Operational Risk Register

In presenting the Risk Register, Mrs Musson advised that the purpose of the report was to provide the Trust Board with the high level Operational risks held across the Trusts Risk Registers. There were 7 risks which are applicable for presentation to the Trust Board.

Page 18 of 21

The risks around the Trusts current estates provision had been discussed at Quality and Safety Committee including the associated impact this may be having upon quality of services. The actions to address this risk were detailed in the report and Dr Murphy provided assurance that as referred to in his Committee Chair’s report the Quality & Safety Committee had reviewed the risks around estates. Mr Burbeck queried the red RAG rating of the FINAN 1 given the assurance provided to the Board that the Trust would meet its year-end financial outturn. Mr Turner advised the Board that the Committee had previously revised the risk down and Mr Davies agreed to check that the risk register had been updated accordingly. ACTION: Ensure that the Finance & Performance Committee Risk Register accurately reflect the Committee’s risk rating for risk FINAN1. Mr Burbeck also queried the RAG rating of HR002 Section 75 Agreement and Mrs Writtle advised that the risk remained red due to concerns about service delivery but that the risk would be reviewed. ACTION: RAG rating of HR 002 Section 75 Agreement to be reviewed. Mr Rana advised that Risk 289 – changes to the Section136 Policy should be re-worded to accurately reflect the current position. ACTION: Wording of Risk 289 – changes to 136 Policy - to be reviewed. RESOLVED: That the Board

• approved the risks included within the report and noted the action taken to date.

Mr Davies Mrs Writtle Mrs Writtle

205 STRATEGIC DEVELOPMENT & DIRECTION 205.1

Board Assurance Framework (BAF)

In presenting the BAF, Mr Lewis-Grundy advised that the Board Assurance Framework for 2017/18 had been reviewed and revised through discussion at Board Development Session on 30 March 2017. The Audit Committee met on 22 November 2017, to review the adequacy of underlying assurance processes that indicated the degree of achievement of corporate objectives and the effectiveness of the management of principal risks. Whilst the Committee remained assured that this was the case,

Page 19 of 21

supported by a mid-year internal audit of the BAF which gave the highest Level A assurance on the BAF, given the strategic impact of the further delay in the TCT integration date, it wished to ensure that the document remains live and therefore requested that the BAF be reviewed in quarter through the Board Committees. The BAF was therefore reviewed again by the Finance & Performance and Workforce Committees on 27 November 2017 and the Quality & Safety Committee on 13 December 2017 to review the Strategic Risks on the BAF within their respective remits, particularly in light of the delay in the integration of the partner Trusts under the TCT Partnership. Mr Lewis-Grundy asked the Board to note the increase in risk around the management and maintenance of estates and that this risk has been escalated during Q2. A further review would take place in Q3 and the BAF would be received by the Board in February after the Committee review process had been completed. RESOLVED: That the Board

• was assured that the Strategic Risks that form the BAF were being managed appropriately.

• reviewed the Board Assurance Framework at the interim period between quarters 2 and 3 – 2017/18

206. FOR ASSURANCE

206.1 MERIT NED Assurance Group – report of the meeting held on 30 October 2017

In presenting the report, Mr Turner confirmed that the group had received the following:

• Risk Register • Programme Update report • Programme Implementation Plan

Mr Turner advised that the Group had agreed to a proposal that as the funding for the Vanguard came to an end and the work was embedded into the usual business of the Trusts the NED Assurance Group would cease at an appropriate time.

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

Page 20 of 21

206.2 MExT Chair’s report from 19 December 2017.

In presenting the report Mr Axcell advised that MExT had received verbal updates from:

• Chief Executive • HR Director • Nursing Director • Operations Director • Joint Medical Directors • Communications & Engagement Manager

The following matters were discussed:

• Cold Weather Plan which was agreed and would be incorporated in the Trust’s Winter Plan

• Freedom to Speak Up Update • Service Line Reviews and Month 7 performance • Progress in reviewing the Trust’s Evacuation &

Shelter Plan • The financial Position at month 7 • Service Developments and business growth • An update on the Trust’s Cost Improvement

Programme • Commencement of amendments to the Mental

Health Act 1983 • TMS pilot evaluation • IAPT Recovery Plan

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

188. ANY OTHER BUSINESS

There were no items of any other business.

189. Questions from the Public

There were no members of public present.

190. DATE AND TIME OF NEXT MEETING

The next Trust Board meeting would take place 3.00pm on 11th January 2017, The Board Room, Canalside, Bloxwich.

Meeting closed at 4.17pm. Signature……………………………………………………….. Date……………. Mr H Turner, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board

Page 21 of 21

Enc 2 MATTERS ARISING FROM PUBLIC MEETINGS

RAG Action Outstanding Completion date in the future Action Completed

Item No.

Date Added Action Responsibility Due Date Update

133.1 5 October 2017

Quality & Safety Committee Chair’s Report Quality & Safety Committee to undertake a review of the complaints which highlighted poor communication in the Trust .

Mrs Musson March

2018

Agreed at Q&S Committee on 8 November 2017 to review the issues around communications and report back in Q&S in January 2018 with an update to Board in March 2018.

196 11 January 2018

Chief Executive’s Overview Workforce Committee to review the suggestions for encouraging individuals to raise concerns.

Mrs Williams March

2018

197 11 January 2018

OnBoard Visits Executive team to consider ways in which innovation across the Trust could be supported.

Exec Team March

2018

198.2 11 January 2018

Quality & Safety Committee Chair’s Report Communication provided to teams to remain alert to the increased risk of patient suicide in January.

Mrs Musson March

2018

49.1 1 June 2017

Quality & Safety Committee Chair’s Report Undertake a scoping exercise related to

April 2018

1

Item No.

Date Added Action Responsibility Due Date Update

the fire issues to be reviewed by the Audit Committee with a report back to Board via the Audit Committee Chair’s Report

Mr Davies

186.2 7 December 2017

Service Experience Desk Report Q2 CAHMS waiting times to be confirmed outside the meeting.

Mrs Writtle January

2018

Verbal update at meeting. Completed. Closed.

204 11 January 2018

High Level Operational Risk Register Ensure that the Finance & Performance Committee Risk Register accurately reflect the Committee’s risk rating for risk FINAN1. RAG rating of HR 002 Section 75 Agreement to be reviewed. Wording of Risk 289 – changes to 136 Policy - to be reviewed.

Mr Davies Mrs Writtle Mrs Writtle

February 2018

Changes have been incorporated into the Risk Register. Completed. Closed.

2

Board meeting date: 1 February 2018

Agenda Item number: 6 Enclosure: 3

Report Title:

Summary Report of Confidential Session of Trust Board held on 11 January 2018

Accountable Director:

Harry Turner, Chair

Author (name & title):

Paul Lewis-Grundy, Company Secretary

Purpose of the report: Best practice in corporate governance requires that business considered in private session is reported into the public session as soon as possible. Given the arrangement of the Board meetings, the earliest opportunity is at the public session of the following month. This report outlines the business considered in private at the meeting of the Board held on 11 January 2018.

Action required from the Board Decision / Approval

Gain assurance

Discussion

Information

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

Committee: None

Date reviewed: N/A

Key points or recommendations from Committee:

N/A

Strategic Objective(s) to which this paper relates:

High quality services

Inclusive partnerships

Leadership culture

Responsible workforce

Supporting strategies

Effective/efficient resources

The CQC domains that this report relates to are:

Please give brief details:

Caring

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

Effective Well-led Safe Enc 3 summary of confidential session 11.1.18 (Final) Page 1 of 2

Title Summary Report of Confidential Session of Trust Board

held on 11 January 2018 Introduction This report outlines the business considered at the meeting of the Board held in private on 11 January 2018. Summary of key points, issues and risks On 11 January 2018 the Board received the following reports: • An update from the Chief Executive • Transforming Care Together (TCT) Partnership Progress Report • Service Development & Growth Progress Report • Director of Nursing Update which gave a brief on water management in the Trust • MExT Minutes from the meeting held on 19th December 2018.

Recommendation The Board is invited to note the business transacted in the private session held on 11 January 2018. Board action required The Board is asked to receive this report for information.

Enc 3 summary of confidential session 11.1.18 (Final) Page 2 of 2


Agenda Item number: 7 Enclosure: 4

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

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

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

Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: None

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

N/A




Leadership culture

Accountable workforce





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

Effective

Well-led

Safe

Enc 4 CEO StrategicBrief-February2018-(Final) Page 1 of 7

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

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

Summary of key points, issues and risks CHIEF EXECUTIVE UPDATE Caldicott Guardian – The Trust, as all NHS Trusts are, is required to appoint a Caldicott Guardian. Dr Kate Gingell, who stepped down from her position of Joint Medical Director effective 31 January 2018 was the Trust’s appointed Guardian. The Trust therefore needs to appoint a new Caldicott Guardian. A Caldicott Guardian is a senior person within a health or social care organisation who makes sure that the personal information about those who use its services is used legally, ethically and appropriately, and that confidentiality is maintained. Acting as the 'conscience' of an organisation, the Guardian actively supports work to enable information sharing where it is appropriate to share, and advises on options for lawful and ethical processing of information. Caldicott Guardians should be able to provide leadership and informed guidance on complex matters involving confidentiality and information sharing. The appointment of a Caldicott Guardian was mandated for the NHS by a Health Service Circular: HSC 1999/012. Guidance recommends that a Caldicott Guardian should be (in order of priority):

• An existing member of the Board or senior management team. • A senior health or social care professional within the organisation. • The person responsible for promoting clinical governance or an equivalent function within the

organisation. Subject to approval by the Board of the recommendation, the Trust’s guardian will be required to maintain a level of training to fulfil the role and the Trust will need to ensure that the up-to-date details are included on the Caldicott Guardian Register held on NHS Digital’s website. Action: Approve the recommended appointment of Dr Mark Weaver to the role of Trust Caldicott Guardian. Time to Talk Day – 1 February 2018 is Time to Talk Day, a national campaign that aims to end the stigma around mental health. As a Trust we support this and we are holding our Mental Health Forum today and some mental health awareness workshops aimed at professionals. You can follow the hashtag on twitter #timetotalk Join this year’s celebrations as the NHS turns 70 - The NHS is turning 70 on 5 July 2018. This is an opportunity to get involved in national, regional and local celebrations to mark the achievements of one of the nation’s most loved institutions, to appreciate the vital role it plays in people’s lives, and to recognise and thank NHS staff – the everyday heroes – who are there to guide, support and care for


us. NHS England has created a short animation which details the achievements of the NHS over the last seven decades. More information on how to get involved in the celebrations is also available on NHS England’s website Transforming Care Together – The moving forward action plan approved by Board is now underway and has been accompanied by further discussions with the Executive teams of the 3 organisations. More regular communication is now being shared with staff on progress with TCT. MERIT Vanguard – Continues to make excellent progress in delivering change across the four mental health trusts in the West Midlands. A paper on progress with MERIT to date and a proposal to continue this into 2018/19 is included elsewhere on the agenda. Walsall Together Programme – At the time of writing the Walsall Together Board had not met. The provider across Walsall continue to make excellent progress in developing a proposal for an Alliance model of care for the borough of Walsall. Planning 2018/19 - Although at the time of writing the national planning guidance for 2018/19 has not been received. The Trust are progressing the development of its plan. This includes engagements with staff and managers across the Trust in setting organizational priorities for the coming year. Accreditation of the Trust’s Memory Assessment Service in Walsall – The service has been accredited by the Memory Services National Accreditation Programme (MSNAP). MSNAP is a programme set up by the Royal College of Psychiatrists and works with services to assure and improve the quality of memory services for people with memory problems/dementia and their carers. This is the service’s fourth consecutive cycle of national accreditation since 2010, the Trust continuing to meet the increasingly rigorous quality standards, assuring its compliance through MSNAP accreditation. NATIONAL POLICIES & STRATEGIES The following national strategies and policies have recently been issued. They are potentially relevant to the future strategic, planning and operational management of the Trust and the implications should be taken into account. Each document has been considered with the respective executive directors. This summary is not intended to incorporate all national publications, for instance those issued by National Patient Safety Agency, National Institute for Clinical Excellence or every operational directive issued by Department of Health which should be considered within the Trust by the appropriate department and necessary action taken. 1. Decision Making and Mental Capacity

Published by: Nice Date Published: 4 January 2018

This NICE guideline has been commissioned by the Department of Health as a result of historic concerns raised by the Care Quality Commission. The Care Quality Commission identified serious issues with the practical implementation of the Mental Capacity Act. This guideline covers decision-making in people over 16. it aims to help health and social care practitioners support people to make their own decisions where they have the capacity to do so. It also helps practitioners to keep people who lack capacity at the centre of the decision-making process.


http://informed.cmail20.com/t/d-l-obtrdk-ftlhljdc-j/

http://informed.cmail20.com/t/d-l-obtrdk-ftlhljdc-t/

The guideline focuses on the key areas of: • Advance care planning – supporting people to make arrangements for a time when they may

lack mental capacity to make decisions for themselves, so that their wishes, values and beliefs can guide and inform those decisions

• Supported decision-making – ensuring that people who have the mental capacity to make specific decisions for themselves are given the help and support they need to do so

• Assessment of mental capacity to make specific decisions at a particular time • Best interests decision-making – using the provisions of the Mental Capacity Act to make

decisions for a person who has been assessed as lacking mental capacity to make that specific decision for themselves; maximising the participation of that person in the decision-making; considering their wishes, values and beliefs; and ensuring appropriate access to independent advocacy services.

The Consultation closes on 5 February 2018 Action: Review and consider whether to respond to the consultation Web-link https://www.nice.org.uk/guidance/indevelopment/gid-ng10009/consultation/html-content-3?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=9011255_NEWSL_HMP%202018-01-02&dm_i=21A8,5D54N,M5T16P,KQK21,1 Executive Director: Interim Director of Operations Board Committee: Mental Health Act Scrutiny Committee 2. NHS Standards Contract 2017-19 (January 2018 edition) and National Variations

Published by: NHS England Date Published:

The NHS Standard Contract is mandated by NHS England for use by commissioners for all contracts for healthcare services other than primary care. Commissioners are required to ensure that the appropriate National Variation is implemented for all of their contracts, to take effect from 1 February 2018. Where commissioners are placing new contracts with providers, they must now use these updated versions of the relevant Contract with immediate effect.

A summary of the changes we have made to the Contracts can be found in section 3 of the NHS Standard Contract Technical Guidance. Details of the changes can be found in a comparison documents also published on NHS England’s website. Action: The updated contract is being applied to the 2018/19 commissioning agreements. Web-link https://www.england.nhs.uk/nhs-standard-contract/17-19-updated/ Executive Director: Director of Finance, Performance and IM&T Board Committee: Finance & Performance Committee 3. Nursing Associates’ fees consultation

Published by: Nursing and Midwifery Council (NMC) Date Published: December 2017

The Nursing and Midwifery Council (NMC) is seeking views on the proposed fees for the new nursing associate role that will be introduced in England. It was agreed by the NMC, following a request from the secretary of state, to regulate nursing associates. This consultation sets out how the registration fees, that the NMC will charge nursing associates in order to regulate them and how the fee links to the processes that we will use to register nursing associates. If the NMC’s legislation is changed on time, a new nursing associate part of their register will be planned to open in January 2019. The consultation runs to 26 February 2018.


https://www.nice.org.uk/guidance/indevelopment/gid-ng10009/consultation/html-content-3?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=9011255_NEWSL_HMP%202018-01-02&dm_i=21A8,5D54N,M5T16P,KQK21,1



https://www.england.nhs.uk/nhs-standard-contract/17-19-updated/

Health Education England has announced new funding to support the roll-out of 5000 nursing associate roles, with additional funding for employers. The nursing associate apprenticeship standard will be the delivery model for this programme. Action: Review and consider whether to respond to the consultation Web-link https://www.nmc.org.uk/globalassets/sitedocuments/na-hub/nursing-associate-fees-consultation-2017.pdf Executive Director: Acting Director of Nursing Board Committee: Workforce Committee 4. Research launched to investigate health and care spending needs for the next 15 years

Published by: NHS Confederation Date Published: 11 January 2018

NHS Confederation has announced a comprehensive study into the needs of the UK’s health and care systems for the next 15 years. The work, which will be undertaken by the Institute for Fiscal Studies (IFS) and the Health Foundation, will aim to identify the challenges faced by health and care services, as well as to provide objective evidence of what will be needed in the future. It is hoped that the research will be used to inform political and public debate about what will be required to deliver a health and care system fit for the 21st century. The first of two reports will be presented at the confederation’s annual conference in June 2018, summarising UK spending trends since 2002, with projections for funding requirements until 2032 and will include an assessment of the scope for increased effectiveness and productivity to deliver the best value for money, and compare the UK’s health and care spending to that of other comparable countries. It will also propose potential options for methods of raising additional funding. The second report will be published towards the end of the year, examining how well the NHS is performing relevant to its principle of “providing a comprehensive service, which meets the needs of all.” Action: To note Web-link http://www.nhsconfed.org/news/2018/01/nhs-confederation-teams-up-with-independent-experts-for-study-into-health-and-care-funding Executive Director: Chief Executive Board Committee: Board 5. No Hospital is and island – learning from the acute care collaborations

Published by: NHS England Date Published: 12 January 2018

This report covers the learning from 13 acute care collaborations that were established in September 2015 as part of the new care models programme. It highlights six common strategies that have emerged, including the way clinical practices are being standardised; how vanguards are making better use of clinical support services; and how the skills of healthcare professionals are being used more creatively and flexibly. Action: Implications of this to be considered as part of new model of care development in both boroughs. Web-link https://www.england.nhs.uk/wp-content/uploads/2018/01/acute-care-collaboration-learning.pdf Executive Director: Chief Executive Board Committee: Board Enc 4 CEO StrategicBrief-February2018-(Final) Page 5 of 7

https://www.nmc.org.uk/globalassets/sitedocuments/na-hub/nursing-associate-fees-consultation-2017.pdf

https://www.nmc.org.uk/globalassets/sitedocuments/na-hub/nursing-associate-fees-consultation-2017.pdf

http://www.nhsconfed.org/news/2018/01/nhs-confederation-teams-up-with-independent-experts-for-study-into-health-and-care-funding

http://www.nhsconfed.org/news/2018/01/nhs-confederation-teams-up-with-independent-experts-for-study-into-health-and-care-funding

https://www.england.nhs.uk/wp-content/uploads/2018/01/acute-care-collaboration-learning.pdf

6. High impact change model: managing transfers of care

Published by: Kingsfund Date Published: 7 January 2018

This change model, developed with the Association of Directors of Adult Social Services, outlines a practical approach to managing patient flow and hospital discharge. It identifies eight system changes that will have the greatest impact on reducing delayed discharge. The resource supplements the model by bringing together examples of work being undertaken across the country, for each of the eight system changes. Newton Europe have also published a report detailing practical support provided in three localities in the North of England to tackle the long-term challenges of delayed transfers of care from hospital settings. Why not home, why not today? looks at a combination of analytical and operational evidence to underpin a common understanding on how best to reduce the number of people remaining in hospital, when they could have been cared for more effectively in a different setting. The work explores the behaviours, findings and key causes identified, offering a practical approach and suggestions for how others might use this experience to tackle delays and improve system working in their own health and social care systems. Action: Review in line with the Trust practices Web-link https://www.local.gov.uk/sites/default/files/documents/25.40%20High%20Impact%20Change%20model%20CHIP_03.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=9053448_NEWSL_HMP%202018-01-16&dm_i=21A8,5E1OO,M5T16P,KVO3U,1 Executive Director: Interim Director of Operations Board Committee: Quality & Safety Committee 7. Revised Never Events Policy and Framework

Published by: NHS Improvement Date Published: 17 January 2018

Following NHSI’s recent consultation, a revised version of the Never Events policy and framework and updated Never Events list have been published. This list now includes two additional types of Never Event.

These provide clarity for staff providing and commissioning NHS-funded services who may be involved in identifying, investigating or managing Never Events and ensuring there is a focus on learning and improvement.

The revised policy and framework come into effect on 1 February 2018, in line with the updated NHS Standard Contract 2017-19. Local policies and procedures need to remain in-line with the revised national policy and framework. Action: Review the Trust’s policies and procedures to ensure they remain in line with the revised national framework. Web-link https://improvement.nhs.uk/uploads/documents/Revised_Never_Events_policy_and_framework_FINAL.pdf and https://improvement.nhs.uk/uploads/documents/Never_Events_list_2018_FINAL_v2.pdf Executive Director: Acting Director of Nursing Board Committee: Quality & Safety Committee Enc 4 CEO StrategicBrief-February2018-(Final) Page 6 of 7

https://www.newtoneurope.com/content/sectors/NEW0164_DTOC_Brochure_Online_Spreads_1.0_1.pdf

https://www.local.gov.uk/sites/default/files/documents/25.40%20High%20Impact%20Change%20model%20CHIP_03.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=9053448_NEWSL_HMP%202018-01-16&dm_i=21A8,5E1OO,M5T16P,KVO3U,1



https://improvement.nhs.uk/uploads/documents/Revised_Never_Events_policy_and_framework_FINAL.pdf

https://improvement.nhs.uk/uploads/documents/Never_Events_list_2018_FINAL_v2.pdf

8. Health Education England Mandate: 2017 to 2018

Published by: Department of Health and Social Care Date Published: 17 January 2018

The mandate to Health Education England (HEE) sets out the government's objectives for HEE to provide healthcare education and training. It reflects strategic objectives around:

• Workforce Planning • Health Education • Training and Development

The mandate looks at how to develop the healthcare workforce to improve care for patients through education and training. Action: The mandate will be reviewed and an update provided to Workforce Committee Web-link https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/674419/HEE_mandate_2017-2018.pdf Executive Director: Acting Director of People Board Committee: Workforce Committee Recommendation It is recommended that the Board: • Considers and discuss the information contained within this report, and note for assurance the

actions identified throughout the report. • Approves the recommended appointment of Dr Mark Weaver to the role of Trust Caldicott

Guardian Board action required The Board is asked to:

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


https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/674419/HEE_mandate_2017-2018.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/674419/HEE_mandate_2017-2018.pdf


Agenda Item number: 8.1

Enclosure: 5

Report Title:

Trust Integrated Performance Dashboard (Month 9) including the Performance Dashboard and Contract Performance Report Dashboard


Rupert Davies – Interim Director of Finance and Performance


Makhan Singh - Principal Consultant, Information & Performance

Purpose of the report: To update the Board on all aspects of Trust performance at

month 9 of 2017/18 • Quality and Safety • Service User Experience • Efficiency • Resources


Decision / Approval

Gain assurance

Discussion

Information


Committee: • Quality and Safety Committee considered elements from

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

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

• Workforce Committee considered elements from the Resource and Quality and Safety Domains

Date reviewed

10 January 2018 – Quality and Safety Committee 22 January 2018 – Finance & Performance Committee 23 January 2018 – Workforce Committee


Key points are included in the individual chairs reports to Board, separately on the Agenda.

Enc 5 Cover Sheet 17_18 IPD Month 9 Page 1 of 4

Strategic Objective(s) to which this paper relates: High quality

services


Leadership culture




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


Caring

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

Effective Well-led Safe


Title Trust Integrated Performance Dashboard (Month 9)

including the Performance Dashboard and Contract Performance Report Dashboard

Introduction

• This paper presents the Trust’s performance at the end of month nine 2017/18 financial

year.

• The 2017/18 Integrated Dashboard allows comparison and triangulation across Quality and Safety, Service User Experience, Efficiency, and Resources to give a comprehensive picture of the performance of the Trust.

• The 2017/18 Integrated Dashboard also includes performance, and exception commentary, by service line, so that the Board is better able to see achievements as well as any adverse performance within the overall aggregate level.

Summary of key points, issues and risks

• For 2017/18 the Trust Integrated Performance Dashboard (IPD) has been reviewed by

Operational and Corporate Teams. The IPD has been amended in accordance with the changes to the service lines. Where appropriate the 18 month trends are shown in the IPD and for any new KPI’s under a service line, the in-month position is reported.

Quality and Safety Domain • In December the Trust reported 397 incidents. This is a decrease from 441 in

November. The Trust reported eight Serious Incidents during December (By service: Acute Inpatients - 3, Older Adult Inpatients – 1, Urgent Care - 2 and Community & Recovery – 1 and Outpatients - 1).

• CPA Performance at month nine: Trust is above target for both CPA indicators (Formal Reviews at 96.61%, Copies of Care Plan indicator at 96.27%.

• Note that the response breaches and complaints upheld/not period has been changed from Year To Date to monthly. Breaches for Trust are 5 of 7, although one was outside the control of the Trust.

Efficiency Domain • The Trust’s Cost Improvement Target for the year is £2,500k, however, in order to

ensure the required level of funding to support in year Cost Pressures schemes have been developed to the value of £3,765k. As at month nine £3,371k worth of schemes have been delivered against the target of £3,765k.

• Based on the agreed ‘Agency Cap’ ceiling of £4.05m for the financial year this equates to an overall target of 8.24% based on the Trust’s planned annual pay costs. Current position to date is reflecting a favourable position to plan of 7.62%. Total agency spend


in financial terms has out turned at a spend level of £2,921k across the Trust against a planned spend of £3,061k (giving a position of £139k ahead of plan).

• Vacancies – There are currently 101 Full Time Equivalent contracted vacancies across the Trust meaning the vacancy rate has increased slightly to 9.19% in month nine from 8.59% in month eight

• Turnover – The 12 Month Turnover rate has increased from 12.81% to 13.54%. The percentage turnover, excluding junior medical staff is average compared with other mental health organisations in the NHS

• Sickness Absence – The rolling 12 month sickness rate has increased to 4.13% in month nine from 3.98% in month eight, this is within the Trusts target and the thirteenth consecutive month of being so. In month sickness has increased from 4.98% in month eight to 5.29% in month nine.

• Appraisal – Compliance has reduced to 85.11% in month nine from 83.92% in month eight, which is just above the Trust target of 85%. There are 137 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 178 reported in January 2017.

• Mandatory Training - Mandatory Training compliance has increased to 90.16% in month nine from 89.42% in month eight, which is just above the target of 90% agreed at MEXT for all mandatory training. Essential Skills Training compliance has increased to 73.5% in month nine from 72.2%, this is below target but has been on an upwards trajectory from the last 12 months.

• Further detail

• Please see enclosed Integrated Performance Dashboard and underpinning reports for finance, contractual performance, quality and workforce.

Recommendation

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

and debate accordingly. Board action required

• Debate the content of the reports accordingly.


Integrated Performance Dashboard Month 9 – 2017/18

Enc 5: Appendix 1

Key Message • For 2017/18 the Trust Integrated Performance Dashboard (IPD) has been reviewed by Operational and Corporate Teams. The IPD has been amended in

accordance with the changes to the service lines. Where appropriate the 18 month trends are shown in the IPD and for any new KPI’s under a service line, the in month position is reported.

Quality and Safety Domain • In December 2017 the Trust reported 397 incidents. This is a decrease from 441 in November 2017. The Trust reported eight Serious incidents during

December (By service: Acute Inpatients - 3, Older Adult Inpatients – 1, Urgent Care - 2 and Community & Recovery – 1 and Outpatients - 1). • CPA Performance at month nine: Trust is above target for both CPA indicators (Formal Reviews at 96.61%, Copies of Care Plan indicator at 96.27%. • Note that the response breaches and complaints upheld/not period has been changed from YTD to monthly. Breaches for Trust is 5 of 7, one of which

was beyond the Trust’s control. Efficiency Domain

• The Trust’s Cost Improvement Target for the year is £2,500k, however, in order to ensure the required level of funding to support in year Cost Pressures schemes have been developed to the value of £3,765k. As at month nine £3,371k worth of schemes have been delivered against the target of £3,765k.

• Based on the agreed ‘Agency Cap’ ceiling of £4.05m for the financial year this equates to an overall target of 8.24% based on the Trust’s planned annual pay costs. Current position to date is reflecting a favourable position to plan of 7.62%. Total agency spend in financial terms has out turned at a spend level of £2,921k across the Trust against a planned spend of £3,061k (giving a position of £139k ahead of plan).

• Vacancies – There are currently 101 Full Time Equivalent contracted vacancies across the Trust meaning the vacancy rate has increased slightly to 9.19%

in month nine from 8.59% in month eight.

• Turnover – The 12 Month Turnover rate has increased from 12.81% to 13.54%. The percentage turnover, excluding junior medical staff is average compared with other mental health organisations in the NHS.

• Sickness Absence – The rolling 12 month sickness rate has increased to 4.13% in month nine from 3.98% in month eight, this is within the Trusts target and the thirteenth consecutive month of being so. In month sickness has increased from 4.98% in month eight to 5.29% in month nine.

• Appraisal – Compliance has increased to 85.11% in month nine from 83.92% in month eight, which is just above the Trust target of 85%. There are 137 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 178 reported in January 2017.

• Mandatory Training - Mandatory Training compliance has increased to 90.16% in month nine from 89.42% in month eight, and is just above the target of 90% agreed at MEXT for all mandatory training. Essential Skills Training compliance has increased to 73.5% in month nine from 72.2%, this is below target but has been on an upwards trajectory from the last 12 months.

Trust Level Integrated Dashboard – Commentary

3

Inpatients Service Line Summary • Note that the response breaches and complaints upheld, this period has been

changed from YTD to monthly. Breaches for Inpatient Services is 3 of 3. (1 took 50 days, 1 took 54 days and the other took 83 days),

• This service line has overspent by £323k to month nine. The main areas of pressure have been within Ambleside and Holyrood in supporting special observations and the challenging behaviour of several DToC patients.

• There has been a decrease in month nine sickness to 6.23% (7.41% in month eight).

• Performance for Mandatory Training has increased (83.87% in month eight to 85.60% in month nine). 4

Community Service Line Summary • Note that the response breaches and complaints upheld, the period has

been changed from YTD to monthly. Breaches for Community Services is 1 of 1, this took 49 days.

• Community & Recovery Services position at month nine is £70k overspent. This is being driven by costs around anticipated NHS Property Services charges for properties such as Poplars and Brace Street within Community Estates.

• There has been an increase in sickness levels for month nine to 9.39% (7.57% reported in month eight).

• Mandatory training performance has slightly increased to 91.89% in month nine compared to 91.11% in month eight.

5

Urgent Care & Access Summary • IAPT Project team is in place to review and take action on the needs of delivering an IAPT service, where the Trust needed to increase the target for IAPT KPI’s during

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

• This service line has underspent by £47k to month nine. This is being driven by vacancies across a number of Primary Care and Access teams. • There has been an increase in sickness performance for month nine to 4.76% from 4.08% in month eight. • There has been a slight decrease in performance for mandatory training to 90.61% in month nine (91.20% in month eight). • Appraisals performance has decreased to 79.81% in month nine (82.83% in month eight). 6

Early Intervention Service Line Summary • Early intervention service is reporting EI Teams and CAMHS Services. • This service is below Target for CPA Formal reviews at 93.33% and above Target

for Copies of Care Plan – 95.86%. IM&T continue to work with service leads to address this under performance.

• The Early Intervention service line is underspent by £127k at month nine, which is due to slippages against new funding streams. It is anticipated that this slippage will be utilised during the last half of the financial year in order to meet the expectations set out by commissioners in terms of training.

• Early Intervention sickness has seen a decrease to 4.22% in month nine (4.43% in month eight).

• Performance for appraisals has increased to 90.16% in month nine (89.92% in month eight).

• Mandatory training performance has slightly decreased to 89.83% in month nine (89.97% in month eight). 7

Contract Performance Report Month 9 – 2017/18

Enc 5: Appendix 2

2

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

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

TrendDudley CCG

TrendWalsall CCG

Trend

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

98.86% 97.50% 100.00%

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

3Care Programme Approach (CPA): The percentage of Service Users under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care. (Target: Above 95%)

95.60% 97.60% 95.30%

4Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS (Target: Above 99%)

99.64% 99.92% 99.91%

5Completion of Mental Health Minimum Data Set ethnicity coding for all detained and informal Service Users. (Target: Above 90%)

91.74% 94.19% 93.88%

6 Sleeping Accommodation Breach 0 0 0

7Percentage of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. (Target: Above 50%)

92.31% 88.90% 66.67%

8Completion of IAPT Minimum Data Set outcome data for all appropriate Service Users. (Target: Above 90%)

98.91% 98.88% 98.77%

9The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 75%)

94.10% 92.18% 98.13%

10The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 95%)

100.00% 100.00% 100.00%

11a IAPT - number of people who receive psychological therapies. (Target Dudley: 477 per month) 273

11b IAPT - number of people who receive psychological therapies. (Target Walsall: 361 per month) 150

12IAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50%)

53.47% 62.96%

13 Percentage of patients who are provided a copy of their care plan. (Target: Walsall - Above 95%) 96.27% 97.26%

3

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

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

TrendDudley CCG

TrendWalsall CCG

Trend

14 Delayed Transfer of Care (All Reasons). (Target: Below 7.5%; Walsall - TBC) 4.53% 4.92% 2.66%

15 Inpatient Admissions Gate kept by CRHT. (Target: Walsall - Above 95%) 100.00%

17 Proportion of in-scope patients assigned to a cluster. (Target: (Dudley - Above 95%) 95.60%

18Proportion of patients within cluster review periods. (Target: Dudley M1 >80%;M2>82%;M3>84%;M4>86%;M5>88%;M6>90%;M7>92%;M8>94%;M9-12>95%)

95.43%

19Dudley and Walsall Recovery Outcome Measure - Number of CPA patients assessed using DWROM (Target: Dudley Only: Q1 - >85%; Q2 - >90%; Q3 & Q4 - >95%)

89.02%

20Eating Disorders - % of children & young people who receive treatment within four weeks of referral for routine cases. (Target: Walsall - Above 95%)

100.00%

21Eating Disorders - % of children & young people who receive treatment within one week of referral for urgent cases. (Target: Walsall - Above 95%)

100.00%

22 PLT - number of patients seen on the wards within 24 hours. (Target: Dudley - Above 85%) 100.00%

23 PLT - number of patients seen in A&E assessed within 4 hours. (Target: Dudley - Above 95%) 100.00%

24 CRS - proportion of patients seen within 6 weeks. (Target: Dudley - Above 75%) 90.48%

25 PT Hub - proportion of patients seen within 18 weeks. (Target: Dudley - Above 95%) 100.00%

26 Duty of Candour --- --- ---


Agenda Item number: 8.1.1a

Enclosure: 6

Report Title:

Quality and Safety Committee Chair’s Report

Committee:

Quality and Safety Committee (Q&S)


Dr Simon Murphy – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Key issues & risks The Quality and Safety committee met on the 10 January 2018. The Committee reviewed the following items of business: Upskilling staff in Psychologically Informed Person - Centred Dementia Care The Committee received a presentation by Dr Cook and Ms Emily Hemming on the work they have been leading relating to upskilling staff in psychologically informed person centred dementia. A range of training has been successfully delivered and the results from the evaluation showed a more in depth knowledge and understanding of person centred care The Training was delivered at Dementia UK Conference in Doncaster and there are plans to deliver this at an Older People’s Psychology Conference. It was noted that this training had the potential to generate new income for the Trust. The Committee commended the work undertaken and recommended to the Workforce Committee that the training should be made mandatory for all staff involved in delivering services to people living with dementia. The Committee had an in depth discussion about the Trust’s strategic approach to delivering person centred care. It was agreed that the Committee would receive an overarching report in March which brings together the many initiatives already underway to ensure a strategic approach was being adopted.

Enc 6 January 2017 QS Chairs Report to Board (2) Page 1 of 3

Quality and Safety Report The Quality Report was presented to the Committee for information and assurance

• 397 incidents were reported and this represents a decrease of 10% when compared to November.

• 8 Serious Incidents were logged by the organisation on UNIFY/STEIS and are under investigation.

Detailed discussions took place regarding the serious incidents and the Committee were informed that a Review Meeting to look at incidents, themes and lessons learned is scheduled to take place at the end of January and a report will be brought back to the Committee in February. The Committee were advised that work is ongoing in the Trust to look at all elements of suicide prevention and training needs for staff and a Workshop is to be arranged to look at all aspects in relation to this. The Trust is involved with developing the Walsall wide Suicide Strategy together with the CCG and Public Health. The Committee agreed that a Communication should be sent out to clinical staff to heighten awareness regarding suicide prevention and vulnerability at this time of year. Quality and Safety High Level Risks The Committee reviewed the risk register. There are currently six risks on the register In relation to Risk EF002 – Fire Safety Management – assurance was provided regarding the correlation between the mitigating actions detailed on the risk register and the Trust’s Fire Safety management Plan. It was noted that whilst there had been an improvement to the risk score, the Fire Officer felt that the work with the Fire Doors should be completed before this risk is downgraded to an amber risk. Risk 289 – Section 136 suites were discussed by the Committee and it was agreed that the risk should be broader than the wording in the report because the changes came into effect on 11 December 2017 and this outlined that the necessary services should have been available. Board Assurance Framework – Quarter 3 Review The Committee reviewed the BAF. It was agreed that SR3 – Achieving quality of care - that an amendment had been made to Gaps in Control and Assurance in relation to CQUINs. The action to address the rolling out of the availability of essential skills training for clinical posts had been updated to reflect the proposal to amalgamate Statutory / Mandatory and Essential Training into individual plans for staff members/groups of staff from April 2018. The Committee agreed that on the basis of the review at Quarter 3 - 2017/18 the existing level of assurance should be maintained. Enc 6 January 2017 QS Chairs Report to Board (2) Page 2 of 3

In terms of SR5 – Management, Maintenance and Strategy for the Estates, three additional risks were identified and added and these related to:

• Gaps in strategic and operational management • Lack of front-line staffing within the department • Completion of Premises Assurance Model in Autumn 2017 has identified a wide range

of improvements required The Committee was assured that additional controls have been put in place to add capacity and leadership within the Estates Team. There remains a gap in assurance as the completion and agreement of the Service Level Agreement has not been signed off. There was discussion around the red risk regarding the implementation of the Estates Action Plan. The Committee requested that an update on the Implementation of the Estates Action Plan be brought back to the meeting in February and that the Board be informed of this. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• MEXT • Audit Committee • Governance & Quality Committee • CARM • CQR • Clinical Audit and Effectiveness Committee • Embedding Lessons Group • Regulation and Risk Working Group • Safeguarding Strategic Group • Suicide Prevention Group • R&D Committee • Health and Safety Committee • Infection Prevention Control Committee • Medicines Management Committee • Mental Health Forum • Policy & Procedures Group • Resuscitation Committee

Recommendations and requests for direction The Trust Board is asked to:

• Accept this report for assurance about the exercise of delegated authority by the Quality and Safety Committee


• Endorse the decisions and recommendations made by the Quality and Safety Committee.


Enc 7 Final QS Committee Minutes - 13 12 17 v1.0.docx Page 1 of 20

QUALITY AND SAFETY COMMITTEE MINUTES OF MEETING HELD ON 13 DECEMBER 2017 CONFERENCE ROOM 1, TRAFALGAR HOUSE, DUDLEY START TIME: 9.00 AM Present Dr Simon Murphy Non-Executive Director (Chair) Dr Kate Gingell Joint Medical Director Mrs Rosie Musson Acting Director of Nursing Dr Mark Weaver Joint Medical Director In Attendance Mrs Julie Adams Service Experience Lead Mrs Debbie Cooper HOS Inpatient Services Dr Ananta Dave Clinical Director for Quality and Safety Mrs Olive Hewitt Clinical Quality Improvement Manager Mr Tom Jinks Patient Safety and Compliance Manager Mrs Sharon Latham Interim Vulnerable Adults and Children’s Lead Mrs Natalie Launchbury Patient Safety Data Analyst Mr Paul Lewis-Grundy Company Secretary (Item 26.1) Mrs Rebecca Temple-Purcell Senior Workforce Development Manager Mr Neil Tong Patient Safety Facilitator Mr David Stocks Expert by Experience (Item 14) Mrs Amanda Rose Directorate Administration Lead (Note Taker) Apologies Mr John Burbeck Non-Executive Director Mr Mark Axcell Chief Executive Dr Andrew Campbell Chief Pharmacist Mrs Lesley Writtle Interim Director of Operations Ms Wendy Pugh Director of Operations and Nursing Mr Liam Dolan Associate Director of Operations

Minute No.

Agenda item Action

187 WELCOME AND APOLOGIES

Apologies for absence were noted as above.

188 DECLARATION OF INTERESTS

Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the


Agenda Item number: 8.1.1b

Enclosure: 7


meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. The Committee were reminded that Dr Murphy had been appointed to the position of Non-Executive Director on the Board of Birmingham Health Care Foundation Trust and will continue as a member of the Board for Dudley and Walsall Mental Health Partnership Trust for the immediate future. No other declarations of interests were made.

189 MINUTES OF THE PREVIOUS MEETING

The Minutes of the meeting held on 8 November 2017 were agreed as an accurate record.

190

MATTERS ARISING ACTION SHEET

The Chair asked whether there were any actions from the Minutes which were not included in the Matters Arising schedule. No further actions were raised. The actions were discussed and the following updates provided:

190.1 Item 96 – Clinical Audit & Effectiveness Committee CPA Audit – Meetings have been held with Community Services and one overarching action plan will be developed following the circulation of the CQC Supportive Visits Report. Feedback has been given to Mr Stephens HoS Community Services and he is aware of this plan. An update will be provided to Committee in February 2018.

190.2 Item 109.2 – Acting Director of Nursing and Joint Medical Directors Update - Falls Forum – Mrs Cooper advised that the Falls Forum has been re-energised and a new lead identified. The work plan has been revamped and the training plan has been revisited, training is now being delivered across all inpatient areas. A business case is being prepared for the purchase of assistive technology i.e. RITA this is an interactive tool designed to work with patients so that they do not fall. Mrs Hewitt advised the Committee that this tool is interactive and is reminiscence therapy as well as education. The next meeting is scheduled for January and an update can be made available to Committee following this meeting. The Committee asked for an update in February 2018.

190.3 Item 129.1 – Matters Arising Bed Management Policy – The policy contains a position statement regarding Korsakoffs and it is expected that the policy will be ratified in January. The Committee will be updated by the Policy Ratification Group.

190.4 Item 158.12 –SAB Report – The information has been circulated to the Committee for assurance. Action closed.

190.5 Item 161.2 – SI and Embedding Lessons Report – The Trust appears to be reporting high levels of incidents under the treatment and procedure category and we are reporting fewer incidents under the implementation of care and ongoing monitoring when compared to other organisations


nationally. The Trust will undertake a review of its reporting categories, NRLS will need to approve any changes prior to the system being amended to reflect same. The review will take place at the end of the Financial year. An update is to be provided to the April 2018 Committee.

190.5 Item 163 – Risk Appraisal to Door Top Pressure Sensors – All doors are currently checked by staff on a regular basis and staff also complete regular environmental checks so that they are not reliant on the door alarms. The sensors have not been turned off and it is not feasible to remove the sensors because this will result in other risks. New bedroom doors are being installed and work is scheduled to start on Ambleside Ward, there will be no door sensors. There is a timeframe for the replacement of the doors which is held by the Director of Finance. Dr Weaver asked the door sensors are checked by staff and Mrs Cooper explained how the checks are completed. The Committee is pleased to note progress in this area and will report same to the Board. The Committee will be informed on progress of work completed in April.

190.6 Item 165 – Anti-Barricade Device CAS Alert – all areas have now been reviewed and risk assessments are being completed. An update will be provided to the January Committee.

190.7 Item 175 – CQC – Moving to Outstanding – The Chair reminded the Committee of the importance of continuing to move forward with this work and following the deferment of TCT a new date will be made for the Committee to schedule time to focus on moving from good to outstanding. The Trust’s allocated CQC Engagement Lead is happy to visit Committees and Teams to explain the new ways of working for the CQC. Action: Mrs Musson and Tom Jinks to arrange for engagement lead to present at Q and S and Operational HOS to be invited.

190.8 The Committee agreed the actions completed and approval was given for the removal of the actions closed.

191 FEEDBACK FROM BOARD / Q&S REPORT FROM PREVIOUS MEETING

The Chair took the opportunity to welcome Mrs Latham to the Committee. The Chair advised the Committee that Board discussions had mostly focussed on TCT. The Board also discussed the situation within the Estates Department. The Board also reflected on the position with TCT and the meeting with NHSI. It was acknowledged that there were alternatives to TCT but these options would have certain implications for our colleagues in BCP, including special measures. NHSI have advised us to make good use of the pause to reflect on where we are and how we can move forward. Partnership working needs to be in the mind set of all involved, these lessons have been learnt. Mrs Musson added that other Trusts who have been successful have taken the embracing hearts and minds approach to move forward.


The Trust reviewed the implications of the pause for the quality and safety of services in the context of the reports on the Risk Register, and the Board Assurance Framework.

DEEP DIVE

192 KINVER WARD

Mrs Launchbury gave an introductory overview and took the Committee through the report and highlighted the following key points, issues and risk:

Kinver has generally reported lower levels of incidents than Ambleside prior to August 2017;

Disruptive / Aggressive Behaviours categories saw the most notable increase in incidents;

Kinver has had a challenging group of patients in recent months;

The ward has struggled to fill qualified nursing shifts at night and have had to backfill with HCAs’ at times.

Mrs Cooper informed the Committee that the shift fill rate is on par with other areas. When a second qualified member of staff is not available an assessment is made and on occasions it is felt the ward is better served by having a known Bank or Agency HCA who is familiar with the ward, patients and other members of staff. The Trust is continuing with its rolling program of recruitment to qualified nursing posts for Band 5 Staff Nurses on a monthly basis. Mrs Musson informed the Committee that the Workforce Committee will receive two reports for assurances at the next meeting due to data quality concerns however the Board have received assurances that safer staffing has not been compromised. The Chair noted that the trigger does not appear to be around staffing and Mrs Temple-Purcell asked Mrs Cooper if the incidents were linked to staff turnover. Mrs Cooper explained the factors that had resulted in the noticeable spike in incidents on Kinver Ward and the impact that these had on other patients and the staff and actions taken by the Head of Service. The ward is being supported by the Clinical Director, Head of Service, Inpatient Manager and Senior Clinical Lead who are visiting the ward regularly. Mrs Cooper advised the Committee that the Trust’s Freedom to Speak Up Guardian and Staff Engagement Lead is visiting the ward to support and advise staff. The Chair noted that the incidents were instigated by 1 patient who involved other patients in their plans, and that following a detailed investigation that the alleged safeguarding issues were unsubstantiated. Mrs Cooper informed the Committee that support had been put in place for the staff who have been affected by the allegations and the effect that this has had on the ward.


Dr Weaver thanked Mrs Launchbury for the detailed report and Mrs Cooper for her detailed explanation and highlighted the need to learn lessons and to cascade this learning to staff. Dr Weaver raised the need for staff to receive training so that they can identify behaviours and attitudes early, thus giving the multidisciplinary team time to develop management plans. Mrs Cooper advised the Committee that the Inpatient Manager is very hands on and is utilising her training in personality disorders. Mrs Temple-Purcell informed the Committee that there is specialist training aimed at identifying such behaviour and the Trust is looking at joining in with this training. Dr Weaver reminded the Committee of the importance of addressing this training need so that the Trust can ensure that staff are supported in future incidents. Dr Dave asked the Committee to note the importance of reflective practice in such circumstances and how this can help staff. The multidisciplinary team should review the care plan through a complex case review and this should include patients, carers and advocacy. Dr Gingell noted that the report was very comprehensive however the impact on staff was not well documented and asked how staff feedback is gathered and monitored, and whether staff have regular meetings. Mrs Cooper informed the Committee that the staff have regular reflective practice sessions on all wards which involves psychologists and all senior staff being more visible. The Trust’s Freedom to Speak Up Guardian and Staff Engagement Lead is visiting all wards and attending team meetings on a regular basis. Mrs Musson informed the Committee of work in progress to develop a more robust early warning system that enables staff to understand the trigger points and allows the ward to triangulate information to pull forward a set of early warning indicators. This empowers staff to identify when there are spikes and enables them to act accordingly. Dr Dave explained that the Schwartz Rounds tool is used to bring various elements of a team together in a safe and supportive environment. It allows the team to look at difficult issues and work through them. Mrs Cooper advised the Committee that staff do something similar but the process could be adopted if suitable. Dr Dave agreed to send the Schwartz Rounds process to Mrs Musson and Mrs Cooper. Action: Dr Dave to send information about the Schwartz Rounds process to Mrs Musson and Mrs Cooper. The Committee received the report for assurance and were satisfied that the spike in incidents related to one patient who then encouraged other patients to cause incidents, this patient has now moved to a more suitable placement. In terms of learning lessons a system has been identified for


early identification of issues in the future. The Trust will also liaise with Birmingham Community Health Care Partners to share best practice. The Committee were pleased to note the Freedom to Speak Up Guardian & Staff Engagement Lead’s involvement.

QUALITY AND SAFETY

193 Quality and Safety Report

193.1

Mrs Launchbury presented the Quality and Safety report and highlighted the following:

441 incidents were reported during November and this represents a decrease of 17% when compared to October. The most notable decrease in Clinical Care, Quality and Treatment.

Inpatient Services (Acute) continues to report high levels of Disruptive and Aggressive behaviour.

Older Adult Inpatient Services had seen a slight decrease in incidents.

Two new Serious Incidents were logged by the organisation on UNIFY/STEIS. All the investigations have now commenced and any identified areas for improvement will be managed through the Trust’s Embedding Lessons procedures.

There were 4 incidents graded as moderate or above. Duty of Candour was considered in all cases but they did not meet the criteria.

There were 8 Safety Alert Broadcasts received.

2 Health & Safety Incidents were RIDDOR reportable. The Committee welcomed the change to the table within section 2.2. The Committee noted that the Community Services had seen an increased number of natural death incidents recorded and acknowledged that this was due to staff being aware of the need to report all deaths. Dr Gingell informed the Committee that the Mortality Review Group has been subject to low attendance and the importance of the group needs to be raised. The dates and membership of this group are to be revisited. Mr Jinks informed the Committee about DNA rates for both Mental Health and GP services in relation to self-harm incidents. Mrs Musson told the Committee that these DNAs were discussed at MExT and it was recommended that a further piece of work be completed by the Outpatient Group and the Clinical Directors. Mrs Musson explained that a recent patient story heard by the Board told how the service could be improved by monitoring the amount of drug and alcohol on the wards and asked how this could be moved forward. Mrs Cooper agreed to look at this. Action: Mrs Cooper to investigate how monitoring of the amount of drug and alcohol available to inpatients can be improved on the wards.


193.2 193.3

Mr Jinks advised the Committee that the CQRM group picked up that we are consistently above the national average for harm free care in relation to our older adult wards. Mr Jinks and Mrs Hewitt agreed to meet outside of the Committee to look scrutinise the Safety Monitor. Action: Mrs Hewitt and Mr Jinks to scrutinise the Safety Thermometer to further explore incidents in Older Adults under the harm free care category and provide an update to the January Committee. Mrs Barnsley took the Committee through the Serious Incident Section and reported that there had been a change to the process and that Health & Safety was now included in the wider learning. Mr Jinks advised that the CCGs have scrutinised the Trust’s reports and have been working with the Trust to make improvements to the reports. Actions have been taken to review the Trust’s processes which have included a review of the serious incident reporting template. The Commissioners have noted the positive progress. Dr Dave informed the Committee that she would be available to meet with Commissioners should the need arise. Mrs Musson asked for assurances to be given to the January Committee that all outstanding reports have been signed off by the Commissioners. Mr Jinks informed the Committee that this would be included in the January 2018 report. Action: Mr Jinks to ensure that assurances to be given to the January Committee that all outstanding reports have been signed off by the Commissioners. Mr Tong advised that there were 7 Safety Alert Broadcast received by the organisation via the Central Alerts System; 5 of which required no further action; 2 are being assessed for relevance and 1 requires action in relation to unbranded LED decorative lighting chains. Mrs Cooper updated the Committee on the Safeguarding Training, DoLs and Domestic Violence, MARAC, Safeguarding Children and Vulnerable Adults data. A targeted communication plan is being drawn up and all training will now be mandatory to remove any confusion on the requirements from staff. Mrs Cooper informed the Committee that there were still interface issues with both the local authority and commissioners in terms of the receipt of invitations to attend Child Protection Case Conferences; the designated single point of entry email address is not utilised and the Safeguarding Team are unable to monitor requests, completion of reports and attendance at meetings. The Strategic Safeguarding Group has added this issue to their risk register. Mrs Cooper drew the Committee’s attention to the increase in the number of Domestic Abuse concerns in November and advised that this was due to an


increase in the reporting of historical domestic abuse. Mrs Cooper explained that there have been 4 Position of Trust notifications, 2 cases are ongoing and 2 cases have been investigated and closed as unsubstantiated. The Committee received the report for information, discussion and assurance.

194 Incident Reporting Looking Back

Mrs Launchbury presented the report, highlighting that the increase in incidents is attributed to a rise in incidents in the Inpatient Service Line particularly around disruptive/aggressive behaviours. Also a decision was taken to report care planned clinical holding in relation to personal care needs. The Chair thanked Mrs Launchbury and opened the item for questions. Mr Jinks informed the Committee that there had been changes to how the type of incident had been recorded and explained how the Trust reports categories of incidents. Dr Gingell asked Mrs Launchbury how medical colleagues could be included in the reports. Mrs Launchbury highlighted that medical staff are not automatically included in the circulation of incidents and recommended that this should be addressed. Mrs Launchbury agreed to investigate whether the Trust’s systems can be used to link incident reports with the patient record system in order to include the patient’s consultants in incident notifications. Action: Mrs Launchbury to investigate the possibility of automatically including medical staff into the incident notifications.

195 Quality and Safety High Level Risks This was discussed after item 210.1

Mr Tong informed the Committee that there are currently 6 risks being presented as part of this report. The Chair informed the Committee that he had received a query from Mr Burbeck referencing the TCT situation and the financial impact. Mr Tong informed the Committee that there may be a need to add some TCT risks to operational risk registers from the Trusts TCT risk register going forward. In addition to this Mr Tong informed the committee that there are two specific financial risks, which are presented to Trust Board as part of the High Level Operational Risk Register. The first was in relation to the long term position in relation to CIP and the second risk was in relation to the delivery of the 2017/18 financial plan which is presented to F&P committee. Mr Tong informed the committee that the long term position around CIP had not changed, but the risk in relation to the delivery of the 2017/18 financial plan


195.1 195.2

had recently been downgraded, but remained as a red risk. It was therefore noted that it was more appropriate for discussions in relation to this particular risk to be had at F&P committee. Mr Jinks informed the Committee that the work being completed with TCT colleagues to address the electronic patient records system needs to be reviewed by Execs to provide an intermediate solution dependent upon the length of the delay. Mrs Musson agreed to raise this with her Exec Colleagues at their Exec Comms meeting as some discussions have already taken place at this level. Action: Mrs Musson to ask Exec Colleagues to review the situation in regards to electronic patient records systems in light of the current TCT situation. Mrs Temple-Purcell reminded the Committee of the monitoring measures in place to ensure that the Trust meets it training compliance figures and this is included on the Workforce Committee Risk Register. Mr Tong informed the Committee that Risk 289 was due to be discussed MHA Scrutiny Committee later this week. Mr Tong confirmed that mattresses have been ordered and a schedule of works regarding replacing the bedroom doors at Dorothy Pattison Hospital is now available, this should allow the Fire Risk to be reviewed and reduced to amber. Dr Dave informed the Committee that there had been a lot of work completed around Risk 289 and asked that the Clinical Directors be added to the risk owners in relation to this risk. Action: Mr Tong to update Risk 289 to reflect that the Clinical Directors are part of the risk owners. The Chair thanked Mr Tong for his detailed update and the Committee noted progress against risks and plans for TCT risks for inclusion in the Report to Board.

196 Acting Director of Operations and Nursing / Joint Medical Directors Update

Mrs Musson informed the Committee that all of the Nurse Director updates were agenda items. Dr Weaver advised the Committee that the MCAP audit had been completed but the Trust’s progress against the set target is not known yet. Dr Weaver acknowledged the hard work completed by Dr Iqbal, Olive Hewitt and members of the Quality Improvement team in chasing medical colleagues and ensuring that the notes were available for the audit to be completed. Dr Weaver informed the Committee that at the recent Doctors Away Day it was agreed that the focus would be on business as usual, dealing with


current projects. It was acknowledged that those outstanding projects that have not moved forward because of the TCT pause will need to be included in work plans. The TMS video which featured Mr Stocks was viewed by the group, the video is very good and well done. The Committee were advised that Dr Gingell and Mrs Musson are working on how the Trust’s Executive Directors review Serious Incident Reports.

197 Annual Anti-Ligature Assessment Review

Mr Tong advised the Committee that the annual assessment review had now been completed for all 9 inpatient wards as per Trust policy.

Mr Tong informed the Committee that two new risks have been identified. One being the bedroom wardrobe furniture, the corners of the cabinets are not flush with the ceiling.

The second new risk is the aprons and gloves held within the dispensers at Bloxwich Hospital, these dispensers are situated in bedrooms across both wards.

The Chair thanked Mr Tong for his update and the Committee noted the contents of the report and the actions taken to address the two new risks.

198 Fire Safety Action Plan Update

Mr Tong provided an update to the Committee, highlighting the following:-

All work that has been completed as a result of the Fire Audits is supported by documented evidence and this is being centrally collated.

Fire Marshall training is now being captured on ESR for all Band 5 and Band 6 Inpatient Nursing Staff.

Staff who are relocating from Broadway North to Bloxwich Hospital have been identified as needing to complete Fire Marshall Training.

The roof space at Bloxwich Hospital is to be assessed by a competent contractor.

Bedroom doors are being replaced.

Fire Marshalls are to be trained in Evacuation skills and then these staff will be dual skilled.

A plan is in place to utilise Grasmere ward at Dorothy Pattison Hospital to conduct evacuation trainings. There are plans for training at Bloxwich and Bushey Fields Hospitals.

The Committee received the report for information, discussion and assurance.

EXPERIENCE AND EFFECTIVENESS

199 EBEs Report This item was taken after Item 193 Mr David Stocks joined the meeting.


The Committee took the report as read. Mr Stocks informed the Committee that he had recently attended an event where a Doctor spoke about how he worked as a domestic cleaner for a day and how people viewed and interacted with him. This reminded Mr Stocks of how the domestic cleaners had talked with him about normal, routine things and how this had helped him. Mr Stocks suggested that it would be helpful if staff could experience being a patient for a day so that they are able to appreciate the patient’s experience on the ward area. Mrs Musson informed the Committee that Mr Stocks is part of the House Keeping work group, who are looking at how housekeeping staff can be made to feel involved and valued as part of the team. Dr Gingell welcomed Mr Stocks’ suggestion but advised the Committee that the idea would need to be fully investigated before being implemented. The Committee discussed how this might work in practice and it was suggested that visitors could sit and observe the activity on the ward and then provide feedback on their observations. Mr Temple-Purcell advised the Committee that the new leadership training is being based on observation of staff and providing feedback and that Dementia Mapping is completed in the same manner. Mr Stocks reminded the Committee that when visits are being made to different wards staff should be looking for the positives and providing feedback on these positive areas so that the team get a rounded picture. Mr Stocks informed the Committee that he had developed a self-help tool for himself and was finding it extremely useful on a day to day basis. The Chair advised the Committee that the self-help tool would be further discussed with Mr Stocks outside of the Committee. Mr Stocks informed the Committee of the patients’ involvement in the development of new leaflets, he explained that sometimes the leaflets can be off putting and the opportunity to make the leaflets more friendly was welcomed by all involved. Mr Stocks felt that the leaflets were improving from a service user perspective. Mrs Cooper thanked Mr Stocks for this invaluable work undertaken by him and other patients. Mr Jinks asked Mr Stocks if EBEs could assess the standard of leaflets available on the ward areas and if they contain the information that they required, and if sufficient numbers of leaflets were available. Following a request from the EBEs to receive feedback in relation to their October Feedback. The Chair requested that Mrs Rose circulate the feedback to the relevant managers and collate the response on behalf of the


199.1

Committee. Action: Mrs Rose to circulate the EBEs October Feedback to responsible managers for their response and to collate same on behalf of the Committee. Mr Stocks left the meeting. Mr Aslett joined the meeting.

REGULATION AND COMPLIANCE

200 CQC Action Plan Update

Mr Jinks presented the report and informed the Committee that good progress is being made, it has to be noted that some of the action dates have expired:-

The handover Policy is due for ratification in December 2017;

The format for the Positive Behavioural Support Plans has only recently been implemented therefore a request has been made for this work to be audited in quarter 4 rather than quarter 3;

Progress continues to be made on the Therapeutic Day and a business case requesting funding is being completed for presentation to MExT.

It has become clear that the planned work by Cardiff University is not suitable for the Trust’s services and Mr Stephens HoS Community Services is to provide an update to the CQC Steering Group.

The CQC Steering Group will provide assurances and updates for all red rated actions to the January Committee. The Committee received the report for information and discussion.

201 Integrated Performance Dashboard

The Committee received the Integrated Performance Dashboard report for information. Dr Dave highlighted that the report made a link between the care and the quality of service delivery.

202 Summary of External Peer Review Assessments

Mr Jinks informed the Committee that there was nothing to report but reminded the Committee of the need for this to remain a standard agenda item.

203 Saville Action Plan Update

Mr Jinks presented the report and advised that the Safe Guarding Strategic Group had reviewed the action plan and are pleased to report that all actions


are rated green. Mr Jinks informed the Committee that NHSi also monitor the Trust’s assurances against this action plan. Mr Jinks asked the Committee to note that Item 6 – Access to the Internet by patients and visitors – is to be reviewed. The Committee received the report for information and assurance. To be included in the Chair’s Report to provide assurance to Trust Board

204 Quality Improvement Priorities and CQUIN Update – Quarter 2

204.1

Mrs Hewitt presented her report to the Committee and highlighted the following items:- CQUIN 1 - Improving physical healthcare to reduce premature mortality in people with serious mental illness (PSMI). Mrs Hewitt informed the Committee that there are low completion rates for cardio metabolic form and/or limited documented evidence of physical health results and interventions and there has been a change in audit parameters. There is no clarity on how the audit will be scored or how payments will be made. CQUIN 3 – Improving services for people with mental health needs who present to A&E. Mrs Hewitt informed the Committee that progress had been made but due to the complex nature of the CQUIN’s requirements the milestones have not been fully met within quarter 2. CQUIN 5 – Transitions out of Children and Young People’s Mental Health Services. Mrs Hewitt advised the Committee that the engagement and implementation plans have been completed but that there has been a delay in submission to the CCGs whilst waiting for sign off from the lead GPs. Quality Priority 1 Smoke Free. Mrs Hewitt informed the Committee that a relaunch of the Smoke Free campaign is underway. Mrs Hewitt advised the Committee that BCP colleagues have arranged a meeting to provide feedback from their pilot site and have invited DWMH ward staff to these meetings. Dr Gingell advised the Committee that all consultants will be asked to support this work and reminded Mrs Hewitt that there were nominated representatives who should be contacted to support this work. Action: Mrs Hewitt to contact the identified consultants so that they can support the relaunch of Smoke Free work. The Committee received the report for information, discussion and assurance and noted that the Report should be presented to Board as an agenda item.

205 CW Audit and Inpatient Documentation Analysis

This item was deferred until January.


SUB-GROUP EXCEPTION REPORTING/MINUTES

206 Safeguarding Strategic Group

206.1

The Committee formally welcomed Mrs Latham in her new role as Interim Vulnerable Adults and Children’s Lead. Mrs Latham provided the Committee with an updated following the Safeguarding Strategic Group held in November 2017 and highlighted the following areas:

Low attendance at the Safeguarding Strategic Group has been escalated to the Chair of the Group;

There is a requirement to align a NED to the group membership;

The Trust does not have a Named Nurse for Children in post due to our secondment from Birmingham Community Health Care securing another role within the organisation, the Trust is sourcing a solution

Mrs Musson informed the Committee that following discussions with relevant colleagues she will provide an update to the Committee in January 2018. Action: Mrs Musson to discuss the above issues with colleagues and update the January 2018 Committee. The Committee received the report for information.

207 Medicines Management Committee

Mr Aslett provided an overview of the reports submitted to the Committee as follows:-

All audits have been completed in relation to Safe Storage of Medicines;

The Pharmacist Interventions review is well established on the wards and the team are now looking at rolling this work across the community based teams;

Antibiotic Stewardship is in place and antibiotics are being used correctly;

The Antipsychotics in Dementia Audit highlights the need to ensure that medication reviews are documented;

As part of the wider Falls Programme the Medicines Management Team now receive incident reports for any falls and this allows the team to complete medication reviews for any patients where medication may be contributing to the risk of falls.

The Committee received the report for information and assurance.

208 Infection Prevention & Control Committee

Mrs Musson informed the Committee that there had been a reported outbreak of Measles in Birmingham. The Trust has taken action to ensure


208.1

awareness is raised within the organisation. Mrs Musson provided an update on the raised levels of Legionella species found during routine testing on both Blowich Hospital and Bushey Fields sites. Actions have been taken in line with the Trust’s Water Management Plan and advice from the Authorising Engineer. Mrs Musson explained that monitoring is continuing across all sites in regards to our Water Management Plan and additional resources have been identified to support the Estates Team with this work. A Deep Dive will be conducted by the Water Management group to look at any failures in controls. This will take place in January. Mrs Musson expected to report the outcome of the Deep Dive to the January Committee. Action: Mrs Musson to report the outcome of the Water Management Deep Dive to the January 2018 Committee. The Chair asked Mrs Musson to advise him of any adverse test results in the interim period. The Chair stated that whilst it is disappointing for the situation to have arisen the Committee can take assurance from the actions taken.

209 Resus Committee

Mrs Temple-Purcell took the Committee through the report and highlighted the following:-

The Resuscitation Policy has been reviewed and the revised policy is awaiting ratification;

A resuscitation drill has been completed at Bloxwich Hospital and some feedback taken on board for future drills;

Resuscitation Equipment Audits are to be completed in the coming weeks by the Resuscitation Service Provider and some changes have been made to the ward equipment audit tool. Regular feedback will be given to the Head of Service and the Inpatient Service Line meetings so that actions can be taken to address any issues in a timely manner;

A report from a planned equipment audit in the community based teams is awaited so that the Trust has a true picture of equipment held by the community teams;

There continues to be concerns regarding the low level of compliance for Resuscitation Training. It has been agreed to explore a “core trainer model” for Basic Life Support so that work place based training can be utilised to increase training flexibility;

There continues to be concerns regarding the management of Oxygen supplies and safe use. Clarification was sought around safe storage and use which is not covered in the newly drafted Oxygen Policy. There are concerns from an operational perspective in


209.1 209.2

relation to oxygen storage and use and a lack of training for staff in this regard. Further clarification has been requested;

Mrs Musson advised the Committee that she would discuss the safe storage and use of oxygen with Mrs Writtle from an Operational Services perspective and identify and share any good practice that Black Country Partnership may already have in this area.

Action: Mrs Musson to discuss the safe storage and use of oxygen within Operational Services with Mrs Writtle, and identify any good practice that can be shared across the two Trusts. Mrs Musson requested a summary of the training issues identified from Mrs Temple-Purcell so that these could be raised with Executive colleagues. Action: Mrs Temple-Purcell to provide Mrs Musson with a summary of the identified issues around training so that Mrs Musson can raise with following Executives. Mr Burbeck raised a query via the Chair, regarding whether the TCT process had any impact on this work and Mrs Temple-Purcell advised the Committee that work continues “as is”.

210 AGREEMENT OF NEXT QUALITY AND SAFETY AGENDA

The Chair advised that the next agenda would include the standing items from the Reporting and Spotlight Session Schedule and items highlighted in the Matters Arising schedule.

211 ANY OTHER BUSINESS

211.1

BAF This item was taken after Item 189 The Chair explained that Mr Lewis-Grundy had other diary commitments and the Committee were asked to vary the agenda so that the BAF could be discussed at the start of the meeting. The Chair advised the Committee that the Finance and Performance Committee had taken the BAF and Risk Register at the start of Committee, the Committee were happy to adopt the same stance. Mr Lewis-Grundy updated the Committee on the current position of the BAF, reminding the Committee that it was important that the BAF remains live on all agendas. The Committee were asked to review Strategic Risks 3 and 5. The Committee discussed in detail Strategic Risk 3, Failure to achieve quality of care. Mr Lewis-Grundy informed the Committee that the Onboard Walkabouts are now planned and scheduled in diaries. The Onboard Walks protocol will commence in January. In relation to the current CQC Action Plan some of the individual risks have


211.1.1

moved to red due to slippage on agreed dates, the action plan gives a true reflection of the current position. It should also be noted that the action plan is based on the inpatient services however assurance plans have been developed for other areas. Mrs Musson advised the Committee that before the risk rating can be effectively reviewed the CQC Steering Group will need to meet and review the action plan. In relation to Research and Development Dr Gingell informed the Committee the long term issues relating to Research and Development are to be addressed by the TCT however the current situation needs to be reviewed by the Trust to ensure that plans are in place for the interim period. Following discussion, the Committee agreed to review the risk and noted that the risk C12 Research and Development is changed to amber. Action: Mr Lewis-Grundy to update SR3 to reflect the change to the risk rating that moves C12 Research and Development to amber. Dr Gingell asked the Committee to review the risk rating for the MCP in terms of their expectations of what they want provided compared to what we are able to provide. Mr Lewis-Grundy advised that the MCP process is the subject of a Strategic Risk monitored by a different committee therefore concerns will be raised to the Board via the Chairs report. The Committee noted that there is also confusion regarding who should be attending the meeting. The Committee agreed that all other risks would remain the same but the CQC Actions (G5 –G8) time frames need to be changed from November 2017 to March 2018. Action: Mr Lewis-Grundy to update SR3 Gaps in Controls (G5 –G8) to reflect the change to the agreed time frames from November 2017 to March 2018. Mrs Musson informed the Committee that work had been commenced with our TCT colleagues to review our nurse establishment and that this work will be completed and the outcome will be reported back in partnership with our colleagues. Mrs Musson informed the Committee that new guidance circulated by NHSi and NHS England needs to be incorporated in to the Quality Improvement Strategy both internally and with TCT partners. Mr Jinks and Mrs Latham joined the meeting. Mr Burbeck raised a query via the Chair in relation to how visible the Quality Report is. Mrs Musson confirmed that the visibility of the Quality Report presented to the Committee remains unchanged and continues to be shared with the service lines.


Mr Lewis-Grundy asked for clarification on the outstanding action noted against Safer Staffing Assurances and the need for a review of the nurse establishment and of the policy. Mrs Musson confirmed that the review of the nurse establishment is complete and has been feedback to MExT. The review of the policy was drafted from a TCT perspective and now needs to be reviewed internally. Mrs Musson agreed that should now have a completion date of January 2018. The Chair thanked the Committee for their detailed discussion in relation to Strategic Risk 3 and noted that the risk remained amber. Mr Lewis-Grundy drew the Committee’s attention to Strategic Risk 5, Management, Maintenance and Strategy for the Estate. The Chair reminded the Committee that the future of the estate was intertwined with the TCT work. Mr Lewis-Grundy updated the Committee on the current situation within the Estates Department and actions taken by the Director of Finance to support the depleted team and to provide operational leadership by working with Birmingham Community Health Care colleagues. The deadlines are currently set at the end of December 2017 but Mr Lewis-Grundy expects some changes to the dates. The Chair advised the Committee that the Finance Director had raised the above changes to the team with Board. Mr Lewis-Grundy advised the Committee that the team’s capacity has been severely restricted. Mrs Cooper highlighted the impact this risk has on quality and safety. Mrs Musson advised the Committee that the Executive lead for Estates has a meeting scheduled for early January to look at the issues facing the Estates Team and that she will be working with Mrs Writtle to produce a gap analysis for presentation at the meeting. Dr Weaver suggested that whilst the high level support is from a strategic perspective there needs to be more day to day support provided to the team; recent events regarding the snow highlighted the lack of leadership for the team. Mr Jinks informed the Committee that further Estates issues were highlighted during the CQC Supportive Visits to the community based teams, these issues being around a lack of maintenance and heating in the team bases. Dr Gingell asked the Committee to consider recommending that a competent person be engaged to lead the team on a permanent basis. Mrs Musson informed the Committee that Exec Comms have been asked to look at risks around the TCT situation and Estates is one of the areas to be addressed, this is being reviewed by Exec Comms on their next meeting. The Committee were of a view that the Trust should commence recruitment


211.1.2 211.3

in this area and a full assessment of the current situation should be completed. Mr Lewis-Grundy explained that the risk had changed from strategic to operational and that the Committee should record that a gap has been identified in capacity and leadership to maintain the Estate which then impacts on the quality and safety of service delivery. There is now a gap in control in relation to the Estate function and this would require an action around bolstering the service and the Committee have suggested that recruitment to vacant posts should take place. The Chair also asked the Committee to consider the impact on the Fire Safety control work the current staffing situation may have. Mrs Musson informed the Committee that the Facilities Contract needs to be added; this was a joint TCT tender. Mr Lewis-Grundy agreed to review the risk focusing on the leadership gap and the TCT situation due to the number of contracts that were being worked on from a TCT perspective. Dr Weaver raised the importance of understanding the various TCT plans so that the Committee understands the detail behind the plans. The Chair noted that the Committee had discussed these concerns and would ask that the risk rating for SR5 is changed from amber to red with the Facilities Contract tendering process added. Action: Mr Lewis-Grundy to update SR5 to change the risk rating from amber to red and to add the newly identified element regarding the Facilities Contract to the risk. Mrs Musson asked if the Committee could receive assurances that actions have been taken for the February Committee. Mr Lewis-Grundy thanked the Committee for the detailed discussions and advised that he will ensure that the risks are updated as per the discussions. The BAF will then be reviewed by the Committee in January 2018. The Chair welcomed the opportunity to discuss the BAF and review progress. GOLD Situation (this item was discussed after item 209) Mrs Cooper informed the Committee that RHH were at gold status and had requested that the step down beds at Bushey Fields were opened for them to transfer patients to. Some urgent work regarding how information is to be captured is being completed and staffing requirements are being addressed. The Committee agreed that the discussions and agreed actions relating to the BAF be included in the Board Report.


212 AGREEMENT OF ITEMS FOR CHAIR’S REPORT TO THE BOARD

The Chair informed the Committee that the Report to Board would be put together from the discussions held in the meeting.

DATE AND TIME OF NEXT MEETING

213 Wednesday, 10 January 2017, 9.00 am – 12.30pm, Board Room, Canalside House.


Agenda Item number: 8.1.1c Enclosure: 8

MENTAL HEALTH ACT SCRUTINY COMMITTEE MEETING

MINUTES OF A MEETING HELD ON 14TH DECEMBER 2017 AT 14:00 HRS CONFERENCE ROOM 1, TRAFALGAR HOUSE, DUDLEY

Members in Attendance: Mr John Burbeck (Chair) Non-Executive Director Mr Neil Tong Clinical Governance Assistant / NHSLA Facilitator Mr Hassan Omar Head of Social Care Ms Rosie Musson Acting Director of Nursing Ms Becky Temple Purcell Senior Workforce Development Manager (part, left

during item 83.1) Dr Mohammad Iqbal Consultant Psychiatrist/Clinical Director Ms Nageena Bibi Mental Health Act Manager In Attendance: Ms Helen King (note taker) Personal Assistant Ms Natalie Launchbury Patient Safety Data Analyst Ms Kelly Plant Clinical Inpatient Manager (in attendance for item

83 only) Apologies: Mr Liam Dolan Associate Director of Operations Ms Wendy Pugh Director of Operations & Nursing Ms Olive Hewitt Clinical Quality Improvement Manager Mr Steve Nash Carers Service Mrs Deb Cooper Head of Service – Inpatients and Home Treatment Ms Lesley Writtle Acting Director of Operations Mr Tom Jinks Compliance & Safety Manager Dr Mark Weaver Joint Medical Director Mr Paul Singh Equality and Diversity Lead Mr Nick Stephens Head of Service – Community Ms Anne Marie Carey Head of Early Intervention, Access and Urgent

Care Services

Minute No

Agenda Item Action

75. APOLOGIES FOR ABSENCE

Apologies were noted as above.

76. DECLARATIONS OF INTEREST

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

Enc 8 MHA S Cttee Minutes 14.12.17 v0.2 Page 1 of 9

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

77. NOTES FROM PREVIOUS MEETING HELD 12TH OCTOBER 2017

The minutes from the previous meeting were agreed as a true and accurate record.

78. MATTERS ARISING

78.1 The actions were discussed and the following updates provided: Item 43.1 Rota and responsiveness issues regarding Walsall AMHPs to be taken via the MHA Scrutiny Committee Chair’s report to Trust Board in September 2017, and then escalated to Walsall Together. Incident chart to be included. A list of incidents had been pulled from the system going back to April 2017 with regards to delays with MHA assessments caused by AMHPs. The data showed 3 incidents. The issue was more to do with contacting AMHPs, or them being unaware they were on duty. This was difficult to monitor, and it only occurred periodically.

Action closed. Mr Omar would pick the matter up at the Partnership Meeting, and would raise the issue at the Committee meeting if it became a concern again in the future.

Action: Mr Tong to send a communication to staff to remind them to report any delays with MHA Assessments which resulted from AMHP issues as incidents so this could be recorded.

Mr Tong

78.2 Item 45.1 Ms Musson to request a spotlight session on the matter of GPs

not attending MHA assessments at the next Contract Quality Review Meeting. This had been requested. Action completed and closed. Mrs Musson to raise the matter at the Committee meeting if it became an issue again in the future.

78.3 Item 63.1 MHA Quality Dashboard Report

Future dashboard report to differentiate between restraint and clinical holding.

Work had been undertaken to separate the data for this Committee


meeting, but gaps had been discovered, which were now being resolved. Action to remain open. Differentiation to be included within the report to February’s Committee.

Dr Weaver to advise medics to inform Ms Temple-Purcell of their MHA training dates so that ESR records could be updated to show an accurate picture.

Mrs Temple-Purcell had not received any information from Dr Weaver. Action to remain open.

Ms Temple-Purcell to look at what training was planned for the MHA, and anticipated attendees, and use this data to set a target to work towards for December 2017, and then again for the end of March 2018.

On Agenda. Action completed and closed.

78.4 Item 64.1 CW Audit Reports

Mr Jinks to liaise with Ms Bibi about changing the capacity form to ensure it had an extra box for the ward name to be entered, and the section 17 leave form had a tick box for ‘has the previous leave form been crossed through’.

Ms Bibi had discussed this with Mr Jinks. The ward name was already on the form, as was a reminder to ensure the previous Section 17 leave form was crossed through. Dr Iqbal also advised that Doctors had reminders in their diary regarding this. Action closed.

Mr Jinks to ensure any actions needing to be communicated from the audits were included within the Embedding Lessons Newsletter, and medical actions were sent to Dr Weaver for him to pick up with medics.

Mrs Cooper advised that results would be included within the next newsletter. Action closed.

78.5 Item 65.1 Dr Weaver and Mr Omar to work on an agreed policy and procedure regarding the use of Section 2 of the MHA for individuals who were arrested by the Police and high risk. This would be discussed later on within the meeting. Action to remain open.

78.6 Item 70.1 Mr Omar to ensure the matter of documentation for tier 4 beds and the medics responsibility to identify a bed was addressed within the deep dive work being undertaken for Quality and Safety Committee. A policy had been put together, which was awaiting ratification. The policy identified Doctors as having as having responsibility for finding a bed. Dr Iqbal would look at the Policy to see whether he was comfortable with it as it was a complex matter, especially within CAMHS.


Action to remain open.

78.7

Item 71.1 Dr Weaver to liaise with Ms Bibi regarding the need for paperwork to be sent to GPs following a decision not to section a patient, and provide an update to the next meeting. Ms Bibi had drafted a form for this; work was progressing. Action closed.

79. MHA QUALITY DASHBOARD REPORT

79.1 Mr Tong took the Committee through the dashboard report, which looked at data extracted on 7th December 2017, and the following was highlighted:

- The number of DoLS cases had reduced (4 in Dudley and 4 in Walsall).

- Physical interventions (restraints/clinical holding) were stable within acute, and older adults had seen a reduction in November 2017. There had been a number of challenging patients, and a number needing help with personal care, which had now been discharged, so the older adult figures should remain low.

- Only 1 abscond had been reported for October/November 2017. The abscond was not being investigated as a serious incident.

- There had been a higher number of patients failing to return from leave. This had been due to patients arriving back from leave late. The Trust took a pragmatic approach when patients were late, and if they had phoned ahead to advise the ward then the Police were not involved.

- There were 4 incidents relating to the MHA; there was no particular theme to note. There was one incident regarding unlawful transport of a patient; this would be discussed later in the meeting.

- It was noted that there was 1 further incident regarding a patient not returning from leave. A warrant had been required. Mr Musson had asked for a strategy meeting to take place. It had been the result of a process failure. Action: Mr Tong to ensure there was an update regarding this incident at the next Committee meeting.

The Chair queried the restraints and clinical holding figures and what level they needed to be at for the Trust to be concerned about them. Dr Iqbal clarified that if the incidents were covered by law, were legitimate, and caused no harm then there was no issue with the amount of interventions. Incidents reported with exception information was considered acceptable, and good use of policy and procedure. It was thought that the Committee should not be too worried about the figures. Mrs Cooper advised that the high number of clinical holding interventions was positive, as this had been actively encouraged as a result of CQC recommendations. Both the CQC and CCG were happy with the interventions, and clinical leads ensured it was being carried out appropriately.

Mr Tong


When restraint was used, independent checks and scrutiny were carried out by the MAPPA trainers, and the safeguarding team. When these incidents had increased in the past it had correlated with increased bank and agency use. Early warning signs, and benchmarking, were being looked at within the Quality and Safety Committee’s work. That work would feed in to this. The Chair was satisfied that appropriate monitoring and process was in place and that the Governance Team had an overarching view. The Committee received the report for information and assurance.

80. INTERNAL AUDIT PLAN

80.1 Mr Tong advised that there were a number of audits completed regarding blanket restrictions and documentation, the actions of which had been fed in to the inpatient assurance documents. The actions were around specific reminders for ward staff. These reminders had been sent and actions had been completed. All audit work was built in to governance arrangements and were discussed at the Inpatient Service Line Meetings which Mrs Cooper chaired.

81. AMHP ACTIVITY AND AUDIT REPORT – QUARTER 2

81.1 Mr Omar explained that when Walsall Local Authority took back their social workers the Trust would need to contact them to request that they undertake MHA Assessments when required. The Trust would also need to consider what data sets needed to be shared with the Local Authority regarding this, as the Trust would continue to monitor this area; Mr Omar and Mrs Writtle were currently in discussion with the Local Authority regarding this. Mr Omar took the Committee through the quarter 2 report, and highlighted the main areas as follows:

- Out of 120 MHA Assessments, GPs had only attended 3. This would continue to be fed back to the CCGs.

- Asian and Black ethnicity patients were still over-represented in assessment figures. The reason was unknown.

The Committee received the report for information and assurance.

82. RISK REGISTER REVIEW

82.1 Mr Tong talked through the Risk Report, which provided the MHA Scrutiny Committee with information on the red risks pertaining to the application of the MHA within the organisation, plus any other applicable risks from operational risk registers, for the period ending 8th December 2017. There was one red risk (risk 289 relating to the Section 136 Policy), and a number


of amber risks. Risk 299, regarding best interest assessments for DoLS had been slightly downgraded. The Chair highlighted that risks 289 and 457 both relied upon Transforming Care Together (TCT) solutions. Mr Tong explained that there was also a TCT Risk Register which was submitted to the Board. Action: Mr Tong to ensure a session with Trust Directors to ensure the TCT Risk Register was reviewed. It was agreed that risk 289 remained a red risk, and would be escalated to Trust Board. Work was ongoing in this area. Discussions were taking place about whether suites were manned or unmanned, and whether the Police stayed at the suite or not. Bed management also needed to be incorporated in to this. Action: Risk 289 to be looked at in line with the TCT integration delay; it needed to be ascertained whether issues were being addressed fully in the current period of delay. Risk 289 also to be re-worded to better reflect the current situation. Risk 457 was also being progressed under the new TCT Mental Health Legislation Committee. Mrs Musson stressed the need to ensure the Trust was staffed safely itself. This had been discussed at a previous Committee meeting. The Trust did not have a Mental Capacity Act lead. Action: Mrs Musson to liaise with Mrs Writtle about Risk 457 and how this was being taken forward. Risks 333 and 360 had not been reviewed since August 2017. Risk 360 regarding DoLS assessments was still relevant as there were still delays. It was noted that there was a delay nationally; the Trust could not do anything about this risk. Staff had been advised to chase Local Authority staff, and document this appropriately each time. Action: Risk 360 likelihood scoring to be reviewed, and risk 333 to be updated for the next Committee meeting. The Committee approved the Risk Register.

Mr Tong

Mr Tong

Mrs Musson

Mr Tong/ Mrs

Cooper

83. SPOTLIGHT SESSION - BEHAVIOURAL SUPPORT PLANS

83.1 Ms Plant, Clinical Inpatient Manager, was in attendance to present the spotlight session presentation on Positive Behavioral Support which outlined the steps being taken to introduce this piece of work. She explained that it was a values based multi-component approach to supporting individuals which involved them and a wider circle of support. It had been shown to enhance quality of life and reduce behaviors that lead to restrictive interventions. All managers were helping build and deliver this work which was very positive. The current position had been captured and an audit would be completed after quarter 4 regarding implementation to see whether the plans were having an impact.


Mrs Temple-Purcell left the meeting. It was explained that responsibility needed to be handed back to service users; many service users wanted to be involved in their care. With regards to primary intervention, the Trust referred in to other services, worked with the councils and community services, and signposted elsewhere if required. The Chair queried how success would be measured, as if success could be demonstrated more capacity could be requested. Ms Plant explained that it should be evidenced in a reduction of interventions and restraints. A case study could be undertaken once the work was more embedded and used as an example of success. Monitoring could be undertaken through the Service Experience Desk, and the Governance Team from a compliance point of view. The work would feed in to the Restrictive Practice Group. It was explained that therapeutic staff were being involved; the vision would be shared at an upcoming Inpatient Therapeutic Day. The Chair commended the excellent work undertaken. The Committee supported the work being undertaken and the timescales outlined within the presentation. The Committee believed it would be beneficial for this presentation to be given at the Trust’s Quality and Safety Committee. Action: Mrs Musson to ensure the Positive Behavioral Support presentation was provided to the Quality and Safety Committee.

Mrs Musson

84. ALM MEETING FEEDBACK

84.1 Ms Bibi advised that there had not been a full ALM Meeting since June 2017. Ms Bibi had met with them informally and they were eager to have a formal meeting. The Chair agreed for this to be undertaken on the 8th February 2018, prior to the Committee meeting on that same day.

85. POLICY UPDATES

85.1 Mr Tong advised that no policies had been updated this month relating to the MHA. All policies were within date. Work was still being undertaken regarding the interagency 136 Policy.

86. AMENDMENTS TO THE POLICE AND CRIME ACT 2017/SECTION 135 AND 136 OF THE MHA

86.1 Ms Bibi had put together a paper outlining the major changes to the Act which was talked through. Main changes were

− The new working definition of a Place of Safety − The broadening of where Section 136 could be used − Shorter detention time − Consultation with a health professional


− Limitation on using a police station as a place of safety for a person under the age of 18

− Police station as a place of safety for adults − Powers to ‘keep’ at a place of safety − New police search powers under Section 136C

Staff had been updated about the changes, and paperwork had been amended as appropriate. The Chair asked what was in place in order to provide advice to the Police prior to them exercising their Section 136 power. Mr Omar advised that the Crisis Team was on hand but that they had limited staff, so if they were unavailable the Police would not have access to this advice. The Management Executive Team (MExT) were discussing this matter on the 19th December 2017, where a position statement would be ascertained, and risks would be looked at, along with actions to resolve any issues. The Chair stressed that capability of the Crisis Team needed to be firmed up as soon as possible. A conversation needed to be held with commissioners about staffing, as currently the Section 136 places of safety within the Trust were unmanned. Mrs Writtle was discussing this with the Police and the Trust’s Chief Executive Officer currently; this would also be discussed at MExT. It was clarified that the TCT integration should mean there was access to a better pool of advice. Mrs Writtle was continuing to have discussions to take this forward. The Chair stressed that the Trust needed to meet the requirements set out by law. The Committee received the report for assurance and approved the actions being undertaken therein. The Chair would ensure the matters discussed were escalated to the Board within the Chair’s Report. An update would be provided at the next meeting.

87. CCG TRAINING REMEDIAL ACTION PLAN

87.1 The Committee had been provided with an update report on the Mental Health Act training compliance and the action being undertaken to improve this, as had been requested at a previous meeting. This was essential training for the Trust’s registered Mental Health Professionals and required to be completed every 3 years. Compliance was current at 64.2%. Compliance targets of 80% by the 31st March 2018, and 90% by the 30th June 2018, had been agreed with the Executive Team. It had also been agreed to standardise terminology, removing the term ‘essential training’ completely, and replacing this with ‘mandatory training’ from the 1st April 2018.


Ms Bibi had agreed to deliver another 12 training sessions between January and March 2018, and there was a focused piece of training being undertaken which would cover inpatients. Training would also be embedded within the e-rostering system. The Committee accepted the contents of the report, and approved and supported the delivery of the plan within.

88. ANY OTHER BUSINESS

88.1 A proposal had been worked up for the TCT Mental Health Legislation Committee. It was clarified for the Chair that the Committee had already compared the Terms of Reference of the new TCT Committee to those currently in place for this Committee. It had been ensured that nothing had been lost from the current Terms of Reference, and that this Committee was undertaking everything it could be prior to TCT integration. Ms Musson explained that she would be gaining clarity on who should be the Executive Lead for this Committee at the next Executive Weekly Communications Meeting.

89. DATE, TIME, AND VENUE OF NEXT MEETING

89.1 Thursday 8th February 2018 at 2.00pm, Conference Room 1, Trafalgar House, Dudley


Meeting date: 1 February 2018

Agenda Item number: 8.1.1d Enclosure: 9

QUALITY REPORT (MONTH 9)

1

Section 1 Summary of Trust Incidents and

Serious Incidents

2

Section 1

Summary of Trust Incidents and Serious Incidents

●High

●Low

13 12 0 0

9 0 0 0

136 7 0 0 0

252518794844

7215121135855

1965 ● 1743 ● 60

17 ● 813 ● 011 ● 59321000

Top

5 C

ause

Gro

up

s &

to

p 3

Inci

den

t C

ause

s

Benchmarking

4304 45 22

Physical Assault - Pt On StaffPhysical Assault - Pt On Pt

Found With Injury

Clinical Care, Quality And TreatmentClinical - Treatment / Care RelatedDeath - Unexpected - Physical Hlth/Sudden IllnessInsufficent Communication - InternalSerious Harming BehaviourSelf Harm - Medication OverdoseSelf Harm - CutSelf Harm - Suicidal/ Self Harm Ideation

8 249

Other

12 months incident data

December 2017 Incidents by Serviceline

Serious Incidents Patient Safety Incidents

12 months SI data 12 months PSI

397

CommunityInpatient UCAS

December 2017

Trust Incidents

Patient AccidentPatient - Faint/ Fit / UnwellFall - Unobserved Fall Mobilising Alone

Information Governance And ConfidentialityDocumentation & Electronic Records ManagementFireInfection Control

Health & Safety

Non Patient Slip Trip & FallExposure To Heat/Cold (Environment)Vehicle/Traffic IncidentAccess, Admission, Transfer DischargeMedication

Mental Health Act

EquipmentSecurity / Cyber SecuritySkin Integrity

Security Incidents Reports

79

12 months SIRS

Behavioural - Destructive / Damage To Property

Verbal Abuse - Pt On StaffBehavioural - Aggressive

Harm

No

Low

Mo

d

Seve

re

220E.I. CSD

Top 3 Incident Categories

December 2017 Incidents by CategoryDisruptive / Aggressive Behaviour

Duty of Candour

13 of the patient safety incidents reported for

December were reviewed but the criteria for

Duty of Candour was not met.

Please see section3 for further information

December 2017 PSI incidents

Active Serious Incident

Investigations 14

1 No Harm2 Low Harm3 Moderate Harm4 Severe Harm5 Death

Physical Assault - Pt On StaffSerious Incidents category in

the last 12 months

Serious Harming Behaviour

Patient Accident

Access, Admission, Transfer Discharge

Disruptive / Aggressive Behaviour

Infection Control

Clinical Care, Quality And Treatment

0%

50%

100%

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

2017

PSI Incidents level of Harm

Section 1 - This section looks to provide a summary of all of the Incidents and Serious Incidents occuring within the Trust.

Trust Incidents - There have been 397 incidents reported within the Trust during the month of December. This represents a 10% decrease when compared to the previous month.

A decrease has been seen across the service lines, with the exception of UCAS, and also across the categories with the exception of Clinical Care Quality and Treatment, and Health & Safety incidents.

Further breakdown by service lines and analysis can be found in Section 2

Serious Incidents - 8 incidents have been reported during the month of December and are under investigation. There are currently 14 active investigations open to the Trust.

A further summary of the Serious Incident cases can be found in Section 3

0.0% 50.0% 100.0%

None

Low

Moderate

Severe

Death

PSI

- H

arm

DWMH Previous Year

DWMH Previous month

55 Mental Health Organisations -12 mth

3

Section 2 Individual Operational

Service line Reports

4

Section 2 - Service Line Reports

Wal Dud Dud Dud Wal Wal Dud Wal Wal Dud Dud Dud Dud

F F mix M M Func Org Func Org

Am

ble

sid

e

Kin

ver

Wre

kin

Cle

nt

Lan

gdal

e

Ced

ars

Lin

den

Mal

vern

Ho

lyro

od

Step

do

wn

11 29 9 12 18 0 0 79 1 8 22 15 0 3 49

0 6 1 2 3 0 0 12 Physical Assault - Pt On Staff 0 3 9 6 0 0 18

2 4 1 0 2 0 0 9 Behavioural - Aggressive 1 4 6 5 0 0 16

2 3 1 2 0 0 0 8 Physical Assault - Pt On Pt 0 0 3 2 0 1 6

15 12 3 1 0 1 1 33 Clinical Care, Quality And Treatment 0 2 11 18 1 2 34

9 2 0 0 0 0 0 11 Clinical - Treatment / Care Related 0 2 8 2 1 1 14

1 7 1 0 0 0 0 9 Clinical Holding 0 0 0 16 0 1 17

0 0 1 1 0 0 0 3 Staffing - Agency Staff Usage 0 0 1 0 0 0 1

2 11 2 4 4 3 0 26 Patient Accident 5 3 10 6 0 2 26

2 8 1 2 3 0 0 16 Patient - Faint/ Fit / Unwell 0 0 2 2 0 0 4

0 0 0 0 0 2 0 2 Fall - Unobserved Fall Mobilising Alone 0 1 0 2 0 1 4

0 0 0 1 0 1 0 2 Fall - Unobserved Fall From Bed 1 0 3 0 0 0 4

4 2 2 4 2 0 0 14 Medication 0 0 4 1 0 0 5

2 2 0 1 1 0 0 6 Administering - Drug Early/Late/Duplicated 0 0 3 1 0 0 4

2 0 2 0 0 0 0 4 Prescription - Misplaced Within Pharmacy/External0 0 1 0 0 0 1

0 0 0 1 1 0 0 2 Administering - Incorrect Dose/Strength/Formulatio0 0 0 0 0 0 0

3 1 1 0 2 0 0 7 Skin Integrity 2 0 1 0 0 0 3

1 1 1 0 0 0 0 3 Health & Safety 0 1 2 0 0 0 3

1 0 0 0 0 0 0 1 Serious Harming Behaviour 0 0 2 0 0 0 2

1 0 0 0 0 0 0 1 Total 8 14 52 40 1 7 122

1 0 2 1 3 0 0 7Security / Cyber Security 0 0 1 2 2 0 0 5Health & Safety 1 0 1 0 2 1 0 5Equipment 0 0 1 0 2 0 0 3Mental Health Act 0 0 2 0 0 0 0 2IG And Confidentiality 0 0 1 0 0 0 0 1Total 37 55 25 24 35 5 1 182

Ho

me

Trea

tmen

t


Clinical - Treatment / Care Related

Insufficent Communication - Internal


Self Harm - Ligature

Tota

l

ECT

December 2017

Dudley Walsall

109 100 2212 month All - Dud - Wal

Adult Inpatients

Ho

me

Trea

tmen

t

Older Adults Inpatient

Physical Assault - Pt On Pt

Behavioural - Aggressive

Behavioural - Destructive / Damage To Property


Older Adults Inpatient

All Inpatient Incidents

304

Dudley Walsall

182 122

Adult Inpatients

73

Top

5 C

ause

Gro

up

s &

to

p 3

Inci

den

t C

ause

s

Top

5 C

ause

Gro

up

s &

to

p 3

Inci

den

t C

ause

s


Discharge - Planning Failure

Clinical - Lack Of Clinical Or Risk AssessmentAccess, Admission, Transfer Discharge

Failure To Return From Agreed Sec 17 Leave

Failure To Return From Leave / Missing (Informal)

Tota

l

Medication

Administering - Incorrect Dose/Strength/Formulatio

Administering - Stock/Supply/Storage/Expiry

Patient AccidentPharmacy - Product Labelling

Self Harm - Self Injury

Self Harm - Cut

60.00%

80.00%

100.00%

Acute Bed Occupancy Older Adults Bed Occupancy

2.1a Inpatient Service Line

*Please note that the above tables show all incident categories, but only the top 3 subcategories for each of the highest reported categories.

5


Section 2.1 This section is focused on Inpatient services and shows the number of incidents reported during the previous month against a comparison for the last 12 months. This section also looks to provide information in relation to the types of incidents reported, and their risk and impact. This section also shows high level information in relation to Incidents reported to the NHS Safety Thermometer, HSE (RIDDOR) and Trust Incidents resulting in the use of Physical Interventions.

Commentary on Section 2.1a

Adult Inpatient Wards Kinver – Although the incident numbers are still high, there has been a slight decrease compared to the previous month. Patient A is attributed to 9 of the 29 Disruptive/Aggressive Behaviour incidents and is a new admission. Treatment plans are being reviewed to manage her risks and behaviours. Patient B and Patient C have been involved in 6 incidents each, and Patient D and Patient E can be attributed to 5 incidents each. Upon review it has been identified that the majority of these incidents relate to verbal racist abuse from the instigator Patient B towards the staff and the aforementioned patients. Patient B is also a new admission and has an appropriate care plan in place. There are 3 particular patients that relate to the 12 self-harming incidents. The methods they use are documented and known to staff and are being managed appropriately. Although incidents for the Clinical Care category are higher than previous months, there have been no trends identified, all incidents relate to separate individuals and are unrelated. Langdale – There has been a significant decrease in incidents reported in comparison to the previous month. Patient F can be attributed to 5 of 18 Disruptive/Aggressive Behaviour incidents. It has been identified that the patient’s behaviour escalates following contact from his mother. Patient G is involved in 4 incidents with other patients, however all of low level. The patient also had a glandular infection which may possibly have exacerbated his behaviour. There are no other identified trends for the ward. Ambleside – No trends have been observed in the Disruptive/Aggressive Behaviour category, however, there is a rise in self-harming incidents reported. Of the 15 incidents reported, Patient H can be attributed to 8. There has been a case conference held for this patient as it was identified that her self-harming attempts are related to her behavioural issues. The patient is being nursed on 1 to 1 observations and PRN medication is being utilised to good effect. Although Patient I has been involved in only 4 of the self-harm incidents, the potential for harm is high. Therefore, the Patient Safety Team are involved with the clinicians to internally review the patient’s plan of care and to formulate a plan.

Older Adults Inpatient Wards Malvern – Patient J has been responsible for 9 of the 22 Disruptive/Aggressive Behaviour incidents. The patient displays unpredictable behaviours which are challenging due to her mental state. Therefore, she is being nursed under Level 2 and Level 3 observations at the nurses’ discretions dependant on presentation and level of agitation. The patient’s risk assessment and care plan are regularly updated and are appropriate which includes encouraging her to spend time in a low stimuli area. She responds well to de-escalation skills and PRN medication has been utilised to ease her agitation with positive effect. Patient K is involved in 8 of the incidents due to his challenging behaviours, fluctuating mental health and capacity. His behaviours escalate when staff assistance is required to place the patient in a comfortable position under his best interests. The patient is also involved in the majority of the Clinical Care incidents as clinical holds are having to be utilised to maintain his personal safety. Therefore, the patient is continually managed on Level 3 observations and the use of holds have been reviewed by the MAPA team who have commented that the staff act in a reasonable and proportionate manner in responding to the patient’s presenting risk behaviours. Holyrood – Patient L is involved in 9 of the 15 Disruptive/Aggressive Behaviour incidents, however all are of a low level and there does not appear to be a noted trend in her behaviour. The patient was placed under a Section 3 MHA and appropriate care plans are in place and she is placed on Level 2 observations. Her medications have been reviewed and amended and a placement has been sourced which is pending funding. Patient M is attributed to 13 of 18 Clinical Care incidents as the use of clinical holds are required to maintain his personal hygiene and care requirements. This is documented in his nursing notes and appropriate care plans and risk management plans are in place. Weekly body maps are requested and completed and the MAPA team are reviewing each incident.

2.1b Inpatient Service Line

6


0

0 1

2 0

2

Older

85

34

awaiting grading

7 Death Non PSI

5 Death

3 Moderate Harm

2 Low Harm

1 No Harm

Acute

143

34

2

1

All Inpatient Incidents

Patient Injuires Staff Injuries

12 month trend

December 2017

90.00%

95.00%

100.00%

DWMH

DWMH 12 month Average

National 12 month Average

Minor 32 13

Moderate 1 1

Major 0 0

Physical Intervention

Injury

Benchmarking NHS Safety Thermometer - Harm Free Care

34

70

36

8 17

Inpatients

Adult Older

Patients Involved

Patients Involved

No injuries were reported as a

result of Physical Intervention

Commentary on Section 2.1c

Injury - There has been a slight increase in the number of injuries recorded in comparison to the previous month. There was 1 moderate staff injury relating to a staff member who slipped on the car park during bad weather, resulting in a sprained ankle, and 1 moderate patient injury recorded relating to a self harm incident requiring stitches.

Physical Intervention - There has been a slight decrease in the use of physical intervention in comparison to the previous month. On the older adults wards, 20 of the interventions were clinical holding in relation to Activities of Daily Living or Guiding And Escorting. On the acute wards 27 of the interventions were on the female wards.

RIDDOR - There has been 1 RIDDOR reportable incident identified within Inpatients Service Line during December in relation to a member of staff who sustained an injury following assisting a patient with personal care.

Actual Impact - There were 2 moderate incidents reported, an attempted suicide by Dudley Home Treatment, which has been reported as a Serious Incident (please see section 3) and a medication overdose on Ambleside Ward, which is being investigated internally. There was 1 suicide reported by Walsall Home Treatment, which has also been reported as a Serious Incident (please see section 3).

There were 2 moderate harm incidents reported on the older adult wards. One relates to a patient who was found to have a fractured wrist, however it is unclear at present whether this was sustained at home, on the ward or at the general hospital. Discussions have been held with commissioners, and our partners in the local general hospital have been asked to support an investigation. The other relates to a 'Stepdown' patient, where upon admission it is was realised that the patient had received an overdose of Lorazepam at general hospital. This has been discussed with the Patient Safety Team at the general hospital and they will be conducting an investigation.

2.1c Inpatient Service Line

Health & Safety Excetive 1

Actual Impact

7


Department & Incident Category Dec

PC MH & TTS 15

Equipment 5

Health & Safety 4

Serious Harming Behaviour 2

Disruptive / Aggressive Behaviour 2

Clinical Care, Quality And Treatment 2

Dudley Talking Therapy Service 12

Equipment 3


Health & Safety 3


Security / Cyber Security 1

Psychiatric Liaison Team - Walsall 6


Psychiatric Liaison Team - Dudley 5



EAS (Dudley) Sandringham 3


Health & Safety 1


EAS (Walsall) 2



Crisis Resolution - Walsall 1

Access, Admission, Transfer Discharge 1

Crisis Resolution - Dudley 1


Grand Total 45

3

2

1

Walsall Locality

5 Death

1 No Harm

2 Low Harm

3 Moderate Harm

7 Death Non PSI Related 1

awaiting grading 1

December 2017

45

All Urgent Care & Access Services 21 24Dudley Locality

Actual Impact

37

2.2 Urgent Care & Access Services

Commentary

Section 2.2 This section is focused on the Urgent Care & Access Servies and shows the number of incidents reported during the previous month against a comparision for the last 12 months. This section also gives a break down of the incidents by Locality, and also shows the level of harm caused. • The monthly (mean) average for incidents relating to Urgent Care & Access Services (calculated using data

from the last 12 months, and as a combination of the previous individual Services) is 28 . • Serious Harming Behaviour was the highest reported category within this service in December, totalling 14.

8 Equipment incidents were reported all relating to IT issues. 8 Health & Safety incidents were reported allregarding site conditions during the bad weather with the exception of 1 relating to heating.

• There were 2 moderate harm incidents reported by UCAS. A patient not previously known to services wasassessed by PLT following an overdose requiring treatment. The incident was later reported when thepatient received a further assessment from EAS. Another patient open to Walsall CRS South was assessedby PLT following an overdose requiring treatment. This has been reported as a Serious Incident (see section3).

• There was 1 suicide reported by PC MH & TTS, which has been reported as a Serious Incident. The patientwas open to Talking Therapies and was due to book another appointment following a holiday overseas

8



CMHTOP Walsall 5


Serious Harming Behaviour 1Access, Admission, Transfer Discharge 1

CRS South (Walsall AM) 3

Disruptive / Aggressive Behaviour 2Clinical Care, Quality And Treatment 1

Memory Services (BVC) 2

Serious Harming Behaviour 1Clinical Care, Quality And Treatment 1

CRS North (Dudley - POP) 2

Health & Safety 1Disruptive / Aggressive Behaviour 1

Woodside (CMHTOP) 2


CRS South (Dudley - HH) 2


Patient Accident 1

Psychological Therapies Hub (Pops) 1Patient Accident 1

CRS South (Dudley - Hales) 1


CRS North (Walsall - Moss) 1


Out Patients (HLC) 1

Serious Harming Behaviour 1Grand Total 20

20

1 No Harm 7

December 2017

All Community Services 9 11

5 Death 2

7 Death Non PSI Related 7

Dudley Locality Walsall Locality

Actual Impact

2 Low Harm

3 Moderate Harm

1

3

2.3 Community Services

Commentary

Section 2.3 This section is focused on the Community Services and shows the number of incidents reported during the previous month against a comparision for the last 12 months. This section also gives a break down of the incidents by Locality, and also shows the level of harm caused. • The monthly (mean) average for incidents relating to Community Services (calculated using data from the

last 12 months, and as a combination of the previous individual Services) is 26.• 3 moderate harm incidents were reported by Community Services during December. One related to a

patient open to CMHTOP, who took an overdose requiring treatment and was subsequently admitted toBloxwich Hospital. An internal investigation has commenced. Another incident was in relation to anpatient open to services, who fell at their care home, sustaining a fractured hip. The final incident was inrelation to a staff member who slipped in bad weather on the car park, resulting in a fracture elbow. Thishas been RIDDOR reported.

• 2 suicides were reported by Community Services during December. A patient who had recently beendischarged back to CRS following a period of Inpatient and Home Treatment care was found hanged (seesection 3). A patient open to CRS was found deceased upon a safe and well check. This has been reportedas a Serious Incident in January and further details will be available in section 3 of the February report.

9



ICAMHS Walsall (Canalside) 10


ICAMHS Dudley (Elms) 5


CAMHS Walsall (Canalside) 3

Security / Cyber Security 2

Health & Safety 1

CAMHS Dudley (Elms) 2



Early Intervention In Psychosis (Walsall) 1


Early Intervention In Psychosis (Dudley) 1


Grand Total 22

1 No Harm 6

162 Low Harm

December 2017

All Early Intervention Services 8 14

Dudley Locality Walsall Locality

22

Actual Impact

2.4 Early Intervention Services

Commentary

Section 2.4 This section is focused on the Early Intervention Services and shows the number of incidents reported during the previous month against a comparison for the last 12 months. This section also gives a break down of the incidents by Locality, and also shows the level of harm caused. • The monthly (mean) average for incidents relating to Early Intervention Services

(calculated using data from the last 12 months, and as a combination of the previous individual Services) is 40.

• Serious Harming Behaviour continues to be the highest reported category for this service line.

• All incidents were Low or No Harm .

10

Section 3 Serious Incidents

11

Section 3.1 - Serious Incidents and Duty of Candour

SI Number Date of Incident Service Line Incident Description Level of response Locality

2017/29698 03/12/2017 Inpatient Services – Home Treatment Completed Suicide - Ligature Comprehensive Walsall

2017/30353 10/12/2017 Inpatient Services – Malvern Ward Death – Unexpected Comprehensive Dudley

2017/30349 12/09/2017 Outpatients Services Attempted Suicide – Medication Overdose Comprehensive Dudley

2017/30667 08/12/2017 UCAS – Primary Care Completed Suicide – Ligature Comprehensive Dudley

2017/30672 13/12/2017 UCAS – Primary Care Completed Suicide – Ligature Comprehensive Walsall

2017/31392 20/12/2017 Inpatient Services – Home Treatment Completed Suicide – Ligature Comprehensive Dudley

2017/31635 25/12/2017 Community Recovery Service North Attempted Suicide – Medication Overdose Concise Walsall

2017/31620 14/12/2017 Inpatient Services – Home Treatment Attempted Suicide – Self Injury Concise Dudley

Table 3.1 - List of Serious Incident raised during the month of December2017

Commentary

The monthly (mean) average for Serious Incidents across the Trust (calculated using data from the last 12 months) is 4.25. Table 3.1 shows a list of the Serious Incidents logged on STEIS during the previous month, this includes details of the service line and nature of the incident. Chart 3.1 illustrates the types of the Serious Incidents that have been reported over the previous 12 months. Details of all active Serious Incidents can be found in the section below.

During December 2017 there have been 12 Serious Incident Investigations closed by the CCG, they have commented on the significant improvement and there is evidence of a robust investigation with learning to benefit future patients.

There are 3 Serious Incidents which remain open outside of the NHSE time frames, these have been returned by the CCG for further assurance. It has been agreed there would be joint meetings with DWMH colleagues and the CCG to provide the assurance required, there has been a slight delay due to availability.

Chart 3.1 - Summary of the Serious Incident types during the last 12 months

64% 12%

8%

8%

4% 4%


Patient Accident

Access, Admission, Transfer Discharge


Infection Control


Chart 3.2 - Total number of Serious Incidents during the last 12 months

0123456789

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

Serious Incidents Average Mean + S.D. Mean - S.D.

12

Section 3.1 - Serious Incidents and Duty of Candour

Standard Apr May Jun Jul Aug Sep Oct Nov Dec

1 0 1 3 1 1 0 0 0

Yes 1 N/A 1 3 1 1 N/A N/A N/A

2 days 1 N/A 0 3 1 1 N/A N/A N/A

Yes 1 N/A 0 2 1 0 N/A N/A N/A

10 days 1 N/A 0 2 0 0 N/A N/A N/ATiming

Duty of Candour applied

Verbal

Timing

Written

Table 3.2 - Duty of Candour 2017-18

3.3 Commentary

This section summarises the Trust’s approach to Duty of Candour in relation to all the moderate and above patient safety incidents for the current financial year.

There were 13 incidents graded moderate or above during December. Duty of Candour was considered in all cases but did not meet the criteria., however patient and/or family engagement and support is in place as appropriate.

3.2 Commentary

This section shows the Trust's compliance when incidents have met the Duty of Candour criteria and provides explanations to any exceptions.

No incidents met the criteria for Duty of Candour during December.

Chart 3.3 - Duty of Candour enacted in incidents of moderate harm and above in the

current financial year

6 12

2

1

7 11 11 5 13

1

1

3

1 1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

N Y

13

Section 3.1 - Serious Incidents - New

SI Number Date of Incident

Service Line Incident Description Status Current Status

2017/30353 10.12.2017 Inpatient Services – Malvern Ward

At 7.30am, patient was checked and appeared to be asleep in bed. At 10.00am patient was checked again and appeared to be unresponsive. Medical Emergency was put out and staff commenced CPR. Patient had been known to services since 30th November 2017, she was then informally admitted to Cedars Ward and later transferred to Malvern Ward. Patient had several on-going physical health problems, of which the following was documented upon admission; Arthritis, Autoimmune hepatitis, Reduced renal function, Hypertension, Hyperthyroidism, Hiatus hernia, Raynaud’s, Intrarenal aortic aneurysm, Bilateral shoulder injury and previous gastric ulcer (10 years ago).

09.03.2018

Investigation remains ongoing. However, the Coroner’s have now confirmed the cause of death as:

Ruptured abdominal aortic aneurysm

Independent clinical facilitators allocated

Strategy Meeting arranged to agree the Terms of Reference.

Condolence Letter sent

2017/30349 12.09.2017 Outpatients Services

Informed by the patient's allocated Medic that his secretary had received a telephone call from Atlantic House, who stated that the patient was found deceased at her home address on the 12th September 2017. The patient was discharged from CRS South on the 27th June 2017 due to non-engagement with the service.

The patient was kept open to the Outpatients case load and was due to be seen in clinic on the 11th September 2017 but did not attend. Her last contact with the Trust's services was with the Home Treatment Team on the 2nd June 2017.

09.03.2018

Investigation remains ongoing.

A decision was made by the Executive Directors, that we would await the outcome of the toxicology from Coroners.

Cause of death was confirmed as the following: 1a) Excessive use of Fluoxetine prior to death and 2) Alcohol Intoxication



Condolence Letter sent, however this has been returned as incorrect address. No other address available.

14


2017/30667 08.12.2017 UCAS – Primary Care Dudley

Patient was found at home by his father hanged from the loft. Patient was not open to services; however, did have previous contacts. The latest was in May 2017; however, following this he was discharged from Primary Care Talking Therapies.

14.03.2018

Independent clinical facilitators to be allocated

Strategy Meeting to be arranged to agree the Terms of Reference.

Condolence Letter Drafted

2017/30672 13.12.2017 UCAS – Primary Care Walsall

Patient was found hanging at his home address. The patient was seen on 5th September 2017 and explained that his divorce had been finalised. No plans/intent to self-harm. Follow up apt. re-arranged. Patient was then seen on 10th October 2017 and explained that he had been in a road traffic accident, was not drinking; however, did drink following the accident.

14.03.2018




2017/31392 20.12.2017 Home Treatment Team Dudley

Patient was found hanging at his home address. On the 20th December 2017, patient telephoned South CRS and spoke to the Triage Worker and advised that he felt down over the weekend as he had been unable to have regular contact with his children and was unsure whether he will see them over Christmas. Patient advised that he had stopped drinking and is taking his medication, as prescribed. Patient did not express any suicidal ideation but wanted to stay at home to reflect on things. Plan: Earlier OPA arranged for 8th January 2018 at 12.30pm.

21.03.2018


Strategy Meeting agreed the Terms of Reference.


15


2017/31635 25.12.2017 Community Recovery Service – Walsall North

Patient took an overdose, requiring treatment at the general hospital. Patient expressed that she had been feeling mithered about her birthday (80th) in February and how she never wanted to turn 80 as she feels she has no future and would be better off dead. This is documented throughout patients notes that she does not want to live past the age of 80. Patient also has a diagnosis of Paranoid Schizophrenia.

23.03.2018



2017/31620 14.12.2017 Home Treatment Team Dudley

Patient went missing and had left a suicide note. Patient’s partner contacted the Police, who were investigating his disappearance. Police later found the patient in a local field with stab wounds to his neck and chest.

23.03.2018



16

Section 3.1 - Serious Incidents On-going

SI Number Date of Incident

Service Line

Incident Description Status Current Status

2017/12423 10.05.17 Crisis – Dudley

Patient was open to CRHT in August 2011, however, was discharged back to the care of her GP in September 2011. Patient’s family made contact with the Crisis Team in April 2017, to say that their Mother's mental health had deteriorated since Christmas 2016. Reported by Street Triage that patient had been found deceased, allegedly by hanging.

STOP CLOCK

Discussed with the Dudley Adults Safeguarding Group regarding whether this should be a DHR/SAR or not, however more clarification has been requested from the involved organisations.

Update: Case does not meet the criteria for DHR/ SAR and this SI has now been downgraded by commissioners. A learning review will be led by Dudley Safeguarding Adults with input from our Safeguarding team.

2017/26142 23.10.17 Inpatient Services – Langdale Ward

Patient is informal and left the ward around 13:30hrs for hours out. Police contacted the ward to advise that patient had jumped in front of moving traffic and subsequently ended up in A&E. Patient does not have history of self-harm/suicide attempts, and was not expressing any suicidal ideation prior to leaving the ward. CT scan results indicate the following injuries: fractured right collar bone, tear to the lining of the right lung, broken 7th rib and tendon damage.

19.01.18 Investigation completed, awaiting internal approval

2017/26168 18.10.17 Community Recovery Service – Walsall South

Patient is currently open to CRS South and Outpatients. Patient’s medication is usually locked away by her husband; however, upon collecting her prescription on this day, her husband popped out and the medication was in reach of the patient. Patient then took the overdose whilst at home, which required further treatment at the general hospital.


2017/26382 23.10.17 CRS Dudley Patient overdosed on antifreeze, went into critical care. A Medical Review was scheduled for the 23rd October; however, when staff arrived at the patient’s home, the door was open and he was found on the sofa, unable to communicate.


17

Section 3.1 - Serious Incidents On-going

2017/27009 30.10.17 CRS Walsall – North

Patient took a staggered overdose of medication, which resulted in admission to WMH. Patient is currently open to CRS Walsall South and Outpatients.

30.01.18 Following the Strategy Meeting it was identified from the information that this patients using self-harm when faced with situation, therefore it was agreed to use the investigation to formulate a robust management plan which includes a multi-disciplinary approach.

2017/27013 30.10.17 Inpatient Services – Kinver Ward

Patients on the ward activated the fire alarm, which released the patio gate; resulting in a sectioned patient absconding. Unfortunately, when the patient was running away she experienced a fall, which has resulted in her fracturing her ankle. Patient’s leg is now in a cast, and she is using a wheelchair to mobilise.

30.01.18 Terms of Reference agreed and Table Top Review Meeting arranged

18

Section 4 National Guidance

Central Alerting System

19

Section 4: CAS Alerts

Table 4.1 – Summary of Alerts received during December 2017

Type of Alert

Number of Alerts in December

Action not Required

Assessing Relevance

Action Required

Circulated for Information

MDA 4 4 0 0 0 MHRA 2 1 0 1 0 CMO 1 0 0 0 1 DDL 2 1 0 0 1 EFN 5 5 0 0 0 DH – EFA 1 0 1 0 0 DH 0 0 0 0 0 SDA 0 0 0 0 0 NHS – PSA 0 0 0 0 0 Total 15 11 1 1 2

During December 2017 there were 15 alerts issued via the Central Alerting System, of these 15 alerts:o The Trust is assessing the relevance of 1 alerto alerts required no action takingo The Trust took action in relation to 1 alerto 2 alerts required circulating for information

The table below (4.2) outlines a summary of the alerts issues and any action taken.

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

Alert Date Description of Alert Status Notes / action taken / assurance

EFN/2017/34 05-Dec-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Efacec - 11 kV/433 V Transformers (various ratings)

Action Not Required

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

EFN/2017/35 06-Dec-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - UPDATE - Schneider Electric - RN2c - Ring Main Unit

Action Not Required


EFN/2017/36 06-Dec-2017

High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Hawker Siddeley Switchgear Ltd - HG12 - Circuit Breaker

Action Not Required


EL (17) A/13 07-Dec-2017

DRUG ALERT CLASS 4: SHIRE, BUCCOLAM OROMUCOSAL SOLUTION PRE-FILLED SYRINGES 2.5 MG, 5 MG, 7.5 MG AND 10 MG, EU/1/11/709/001; EU/1/11/709/002; EU/1/11/709/003; EU/1/11/709/004

Action Not Required

The Trusts pharmacy suppliers do not use this particular product

20


Alert Number

Alert Date Description of Alert Status Notes / action taken / assurance

EFA/2017/006 07-Dec-2017

Supply of CNA 2000 pipeline gaskets: presence of asbestos Assessing relevance

This has been sent to the Trusts Estates Department who are currently assessing the relevance of this particular alert

DDL_Gadolinium-Contrast-Agents

13-Dec-2017

Gadolinium contrast agents and risk of tissue accumulation—removal of Omniscan and intravenous Magnevist from February; restrictions to use of other linear agents

Action not required

No action was required in relation to this particular alert as it was superseded by alert DDL_Gadolinium-Contrast-Agents-R

DDL_Gadolinium-Contrast-Agents-R

13-Dec-2017

Gadolinium contrast agents and risk of tissue accumulation—removal of Omniscan and intravenous Magnevist from February; restrictions to use of other linear agents.

Circulated for information

Whilst Trust staff are unlikely to use linear contrast agents. The alert was circulated for information as per the requirement of the alert

CEM/CMO/2017/006

19-Dec-2017

Influenza Season 2017/18: Use of antiviral medicines With surveillance data indicating an increase in influenza cases in the community, GPs and other prescribers working in primary care may now prescribe antiviral medicines for the prophylaxis and treatment of influenza at NHS expense.

Circulated for information

As per the requirement of the alert. This was circulated for information to staff

EL (17) A/14 19-Dec-2017

DRUG ALERT CLASS 4, FOR INFORMATION, WOCKHARDT UK LTD, CO-AMOXICLAV 1000MG/200MG POWDER FOR SOLUTION FOR INJECTION OR INFUSION

Action required: Action complete

The Trusts pharmacy supplier has issued a caution in use memo, should this medication be used as per the requirements of the alert. There was however no affected stock held on any of the Trusts wards

MDA/2017/035 19-Dec-2017

Nasogastric (NG) feeding tubes – recall due to risk of neonatal or paediatric patient choking on ENFIT connector cap

Action not required

The alert required no action taking by the Trust as these devices are not in use

MDA/2017/036 20-Dec-2017

Syringe pumps – required user actions in the event of PL3 alarm to prevent risk of interrupted infusion Action not required

This alert was superseded by alert MDA/2017/036R

MDA/2017/036R

20-Dec-2017

Syringe pumps – required user actions in the event of PL3 alarm to prevent risk of interrupted infusion Action not required

No action required. The Trust does no use syringe pumps such as those outlined within the alert

MDA/2017/037 21-Dec-2017

AlterG Anti-Gravity treadmill, model M320, used for rehabilitation after surgery – unexpected surge to maximum speed and failure of the emergency stop

Action not required

The Trust does not have any anti-gravity treadmills as such no action was required in relation to this alert

EFN/2017/37 28-Dec-2017

Low Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Henley - PC400 - Pole Mounted Fuse Cut-Out

Action not required


EFN/2017/38 28-Dec-2017

Low Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - ABB - SACE - EMAX EN2 12 - Circuit Breaker

Action not required


21


Table 4.3 – Alerts ongoing / currently open

There are currently 3 alerts which have been reported to Quality and Safety Committee in previous months and are currently still listed as open on the Central Alerting System.

Alert Number

Alert Completion date Description of Alert Current Status

EFA/2017/002 19-Feb-2018 Anti-Barricade Devices: risk of ineffectivity in certain circumstances The purpose of this Alert is to advise that in certain circumstances some anti-barricade devices, that may have been fitted to doors to manage the risk of barricade situations occurring, may be rendered ineffective. This increases the risk of avoidable harm and self-harm until the room can be accessed.

Work is ongoing in relation to addressing this alert. A survey of all ward areas has been completed as per the requirement of the alert along with existing mitigations.

Long term actions to rectify issues have been identified (such as the refurbishment of Clee Ward and the installation of new bedroom and bathroom doors on Langdale and Ambleside) within acute inpatient areas.

The survey of all areas noted a difference in standard across most ward areas with anti-barricade devices being inconsistent in design, with bathroom areas (not bedroom areas) appearing to be of the highest risk. It is suggested that whilst there are existing mitigations in place within some areas

As per the requirement of the alert, the “tamper resistance of existing means of entry” has been evaluated for each area. It is suggested that the risk assessments are shared with the Trusts Estates and Capital Planning Group and that the risk assessments are reviewed on an annual basis in line with the Trusts Ligature Point Assessments.

EFA/2017/004 24-Jan-2018 Ideal Standard (Armitage Shanks) A4129A Contour 21 Thermostatic Built in Shower Valve (supplied separately and as part of Armitage Shanks S6960XX Doc M shower packs): Safety inspections required

Ideal Standard has identified circumstances in which the shower can deliver water exceeding the commissioned 41 degree Celsius bathing temperature. Safety inspections are required, with remedial action where necessary.

The Trusts Estates department is currently assessing whether any of these shower valves in use within the Trust

22


Alert Number

Alert Completion date Description of Alert Current Status

NHS/PSA/D/2017/006

09-Aug-2018 This Directive Patient Safety Alert has been issued to ensure confirmation at the end of a procedure that all intravenous (IV) lines and cannulae used for anaesthetic or sedative drugs have been removed or effectively flushed. If this does not happen residual anaesthetic and sedative drugs can later be inadvertently introduced into the patient’s circulation causing muscle paralysis, unconsciousness and respiratory and cardiac arrest.

The Trust is currently assessing the relevance of this alert. It believes the only instance in which the Trust would routinely be using anaesthetics or sedatives intravenously may be within ECT. Further work is ongoing with the Trusts Clinical Inpatient manager and ECT lead to identify whether anything needs to be added to post ECT checklists. The alert has a completion date of 9th August 2018

Table 4.4 –Completed alerts

There were 2 alerts which were reported to Q&S in December 2017 which has now been closed on CAS as the appropriate actions have now been completed.

Alert Number

Alert Completion date Description of Alert

Current Status

MDA/2017/034 ThermoScientificTM OxoidTM CAZ10 CEFTAZIDIME, CT1629B Antimicrobial Susceptibility Test Disc – Concentration of antibiotic decreases if not frozen potentially leading to false resistance results.

The Trust did not have / does not stock any of these devices, as such the alert has been closed

EFA/2017/005 Unbranded LED decorative lighting chains, model CL100: risk of electric shock due to inadequate construction - remove from use

The alert has been shard with estates, cascaded to clinical teams and was circulated on Wednesday wire. As a result of the alert being appropriately communicated, the alert was closed on CAS

23

DWMHT Safeguarding Performance Framework 2017/18

Section 1 • Safeguarding Training Compliance

Section 2 • Deprivation of Liberty (DoL’s) Domestic Violence

Section 3 Safeguarding Children (including CAMH’s – LAC)•Vulnerable Adults

24

Safeguarding Training Compliance Safeguarding Performance

Framework for December 2017

Training Data Month 8

Compliance Target Compliant Required

compliance

Compliant % Compliant Required

compliance


compliance


compliance

Compliant %

Safeguarding Induction 100% 10 10 100% 2 2 100% 5 5 100% 3 3 100%

Safeguarding Adults Lvl 1 90% 259 271 96% 79 82 96% 71 75 95% 109 114 96%



Safeguarding Adults Lvl 4 90% 3 4 75% 0 0 - 0 0 - 3 4 75%

Safeguarding Children Lvl 1 90% 252 271 93% 74 82 90% 71 75 95% 107 114 94%



Safeguarding Children Lvl 4 90% 4 4 100% 0 0 - 0 0 - 4 4 100%

Mental Capacity Act 90% 637 755 84% 264 308 86% 266 318 84% 107 129 83%

PREVENT 90% 681 753 90% 275 307 90% 290 318 91% 116 128 91%

Domestic abuse & Violence 80% 490 715 69% 192 296 65% 218 300 73% 80 119 67%

Compliance Target Oct % Target Compliant

Target

Nov %

Target

Dec %

Target

Compliant

Target

Jan % Target Compliant

Target

Feb % Target Compliant

Target

Mar %

Target

Compliant

Target

Safeguarding Induction 100% 100% 100% 100% 100% 100% 100%

Safeguarding Adults Lvl 1 95% 95% 257 95% 95% 257 95% 257 95% 257 95% 257




Safeguarding Children Lvl 1 95% 94% 256 95% 95% 257 95% 257 95% 257 95% 257




DWMH Trajectory (month 5 as baseline)

447

3

256

696

444

257

699

Compliant Target

DWMH Corporate / Pan Trust12 month

Trend

High point

Low point

Dudley Walsall

Exceptions / Commentary This section shows the latest Training requirement and compliance levels as set out in the Commissioner Contract for 2017/18 , related to Safeguarding and Vulnerable Adults. Within the contract there are agreed trajectory requirements.

Adult Safeguard Training - Children's Safeguarding Training - Q1 - 90% Q1 - 90%Compliance as detailed in the table above. Q2 - 90% Q2 - 90% Q3 - 90-95% Q3 - 90-95% Q4 - 90-95% Q4 - 90-95% Mental Capacity Act (MCA) and Deprivation Of Liberty (DOL’s) Prevent Domestic Abuse Q1 90% Q1 - 90-95% Q1- 60% Q2 90% Q2 - 90-95% Q2- 70% Q3 90-95% Q3 - 90-95% Q3- 80% Q4 90-95% Q4 - 90-95% Q4- 90%

25

NHS

Dudley

NHS

Walsall

Out of

Borough

8

2

10

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1

NHS Dudley 1 2 6 0 0 3 2 7 2 0 5 4 Adult

DOL's Applied For 1 3 2 3 4 11 10 0

DOL's Closed 1 2 6 3 1 4 2

NHS Walsall 3 11 5 0 3 13 3 1 7 5 4 4

DOL's Applied For 1 1 2 1 4

DOL's Closed 3 11 5 3 12 3 1 6 3 3

Out of Borough 0 0 0 0 1 0 0 1 0 0 0 0

DOL's Applied For

DOL's Closed 1 1

Grand Total 4 13 11 0 4 16 5 9 9 5 9 8

Dudley Walsall

MARAC 23 0 28 1

Jul-17

43

6

Safeguarding Cases Internally reported as

Domestic Abuse

Referral

Alert Only

Open To

Mental

Health

Referred

into

MARAC

2016

Open To

Mental

Health

Referred

into

MARAC

Active DoL's

Total

93

9

Linden

Cedars

Holyrood

Malvern

Langdale

2

0

2

Safeguarding Performance Framework for December 2017

Grand

Total

32

13

50

Old

er A

du

lt

2017

19

59

Section 2 - DoL's and Domestic Violence

2.2 Domestic Abuse

Total number of cases of Domestic Violence for the current month, these include cases reported within the Trust and Externally notified by MARAC (Multi-Agency Risk Assessment Conference)

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

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

• There were 8 new DoLS applications made during the month of December; 4 in Dudley and 4 in Walsall. There are currently 11 active DoLS in Dudley or which two were recorded in June 2016 and 10 in Walsall.

Table 2.2 Domestic abuse cases are reported as separate figures to display the prevalence within the service. Case figures are also sh own for MARAC (multi agency risk assessment conference), these figures demonstrate how many cases are heard at MARAC where the victim, perpetrator or children are open cases to mental health. • The first table provides information on cases reported externally of the Trust which are then checked to see if these patient s are open to Dudley

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

26

Referral Alert Referral Alert Referral Alert

4 8 3 8 0 1 24

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

4 8 3 8 0 1 24

7

249

Safeguarding Performance Framework for

December 2017

Dudley Walsall Grand

Total

Child Safeguarding Case

Out of Borough

Patient considered High Risk

Position of Trust Internal

Position of Trust External

Dudley Walsall

Under 18 Admission

Under 18 Death

FGM

Serious Case Review (Child)

Grand Total

Prevent

Grand

TotalNumber of Looked after Children

Total 107 142

3 4New Referrals

3.1 Safeguarding Children

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

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

Table 3.1.1 -This table provides information in relation to Looked after Children (LAC), who have been referred or in receipt of our services.

• Concerns still remain with both commissioners and the local authority as invitations to attend Child Protection Case Conferences for our responsible clincians/care coordinators are not being received as per the agreed process pathway. The pathway identifies a central email account which allows for the correct circulation and enables us to audit attendance and report appropriately. Due to the challenges detailed above the Safeguarding Strategic Group have requested that this concern is added to the Safeguarding Risk Register.

• In Walsall borough Trust involvement with SCRW6 and SCRW7 is currently ongoing. Learning events are being scheduled for SCRW5.

• There was no new SCR activity in the Dudley borough for the month of December.

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

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

New Performance indicators - 2017/18

As part of the new Commissioner Contract for 17/18 additional indicators have been introduced (shown below) for which the trajectors have yet to be agreed. Q1 was to be scoping and trajectory setting for Q2, Q3 and Q4, however this is still to be completed by commissioners and agreed.

No notifications have been received regarding Child Protection Cases during Month

Number of invitations to Initial Chil d Protection Conferences Rate of attendance at Initial Child Protection Conferences Rate of report submission to Initial Child Protection Conferences Rate of report-sharing with parent/child prior to Initial Child Protection Conferences Number of invitations to Review Child Protection Conferences Rate of attendance at Review Child Protection Conferences Rate of report submission to Review Child Protection Conference

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

0

20

40

60

80

100

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

2017Alerts Referral

27

Referral Alert Referral Alert Referral Alert

6 70 13 33 0 0 122

0 3 0 1 0 0 4

0 0 0 1 0 0 1

0 0 0 0 0 0 0

0 1 0 3 0 0 4

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

6 74 13 38 0 0 131

Safeguarding Performance Framework for

December 2017

Dudley Walsall Grand

Total

Grand Total

Adult

Patient Considered High Risk

Position Of Trust Internal

Position Of Trust External

Prevent Case

Serious Adult Review

DHR

FGM

Out of Borough

3.2 Vulnerable Adults

Chart 3.2 - This chart shows the breakdown of the 10 categories of abuse (Care Act 2014) as reported during the month of November.

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

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

• There was 1 Position of Trust internal notification received for the month of December. This was investigated and closed as unsubtantiated.

• There have been 4 Prevent cases identified during the month of December. Two cases were recorded as information only due the patients being subject to Channel as part of the Prevent Strategy and two cases were notifications received from Channel during the month of December which were reviewed and monitored appropriately.

• There is a decrease in Domestic Abuse concerns this month. Upon reviewing the data it appears that there has been a decline in the reporting of historical domestic abuse.

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

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

Chart 3.2 Number of Vulnerable Adults incidents by Nature of Abuse for previous month

51

41

4 5

1

42

8 14

Adults - Domestic Abuse

Adults -Emotional/PsychologicalAdults -Financial/MaterialAdults - Neglect And ActOf OmissionAdults - Organisational

Adults - Physical

Adults - Self Neglect

Adults - Sexual

0

50

100

150

200

250

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

2017Alerts Referral

28


Agenda Item number: 8.1.2a Enclosure: 10

Report Title:

Finance and Performance Committee Chair Report

Committee:

Finance and Performance Committee (F&P)


Harry Turner – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Key issues & risks The Finance and Performance committee met on 22 January 2018 to consider the Finance and CIP information for December (Month 9). The Committee reviewed the following items of business: Performance The report tabled was accepted and the following areas were noted:

• Activity continues to perform above the contracted levels (Month 9 at 5.1%). • KPIs – Under-performance against 2 of the agreed 27 KPI’s;

- DWROM for Dudley (Red) - Number of patients receiving IAPT therapy (both localities – both amber)

• DTOC – currently 4.5% (based on 11 patients) compared to 3.9% last month (14 patients) and 4.2% the month before

• Readmissions – currently 9.5% compared to 11.8% last month and 13.2% the month before.

PbR & Clustering Report The report was tabled and accepted – there was a slight deterioration in the clustering performance in month as compared to the good performance reported last month. Steady progress continues to be made. It was agreed that this report would only be required every other month going forward (i.e. six reports throughout the year). Enc 10 FandP Chairs report Feb Board Meeting (M09) Page 1 of 3

Finance Report The finance report was presented. The financial position to the end of December 2017 showed a £1,408k surplus which was £13k ahead of the plan to date (based on the planned annual surplus of £1,839k). In December Contracted Income reflected a favourable variance of £405k. This has been driven in the main by the expected reinstatement of Complex Care funding and Access QIPPs from Walsall CCG (both at £230k each Year to Date). This has been partly offset by slippage against Detox beds. Income overall is in surplus by £151k which despite the over-performance mentioned above was being deflated by the impact of a pass through of £342k of STP Workforce funds paid to the Trust (pass through). It was noted that combined CCG contracts were indeed over-performing in activity terms, most notably within Walsall CCG, Dudley CCG and Sandwell CCG contracts at a combined notional value of £967,000 however the block contract agreement means that the Trust is not paid for this activity. Agency spend was discussed in light of the NHSI agency cap of £4.05m. The position year to date as of month 9 is reporting an underspend of £139k and has been good progress so far during the financial year. Overall pay spending is in surplus and is continuing to follow the trend of underspends as experienced throughout the previous financial year. CIP performance now reflects a delivery of £3.371m against the £3.8m target for the year. Forecast outturn has shown a move back to the outturn projected in month 7 of £120k. However, it is anticipated that the Trust can and will mitigate this variance and bring it back into line, thus delivering the £1.839m surplus control total at year end. Income and Activity The report was noted and accepted. Again, the Committee agreed to stand down this report going forward as the main headline points and issues were discussed as part of the Finance report tabled at the committee. Contractual Delivery Against Service Lines A verbal update was given around the current position in terms of negotiations with commissioners – host commissioner negotiations are on-going whilst we have had confirmation of agreement with the likes of Wolverhampton CCG. Enc 10 FandP Chairs report Feb Board Meeting (M09) Page 2 of 3

Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

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

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

Enc 10 FandP Chairs report Feb Board Meeting (M09) Page 3 of 3

FINANCE & PERFORMANCE COMMITTEE MEETING

Minutes of a Meeting Held on

Monday 18th December 2017

Conference Room 1, Trafalgar House, Dudley

START TIME: 10:00 HOURS

Present: John Lancaster Non-Executive Director (chair) Dr Mark Weaver Joint Medical Director, Consultant Psychiatrist Ashi Williams Acting Director of People In Attendance: Paul Chamberlain Head of Financial Planning Mark Banks Deputy Director of Finance Dr Kate Gingell Joint Medical Director Steve Byng Head of Clinical Service Development (part attendance) Jeanette Rooke Note Taker Apologies received: Rupert Davies Interim Director of Finance Makhan Singh Principal Consultant, Information and Performance Harry Turner Non-Executive Director (Chair) Lesley Writtle Acting Director of Operations James Parker Commissioner Liaison Manager Pawiter Rana Non-Executive Director

ACTION 84 Apologies For Absence (item 1.0)

84.1 Apologies noted as above.

85 DECLARATIONS OF INTEREST (item 2.0)

85.1

No Declarations of interest were noted.


Agenda Item number: 8.1.2.b

Enclosure: 11

Enc 11 FINAL FP Minutes 18.12.2017 Page 1 of 6

86 Minutes of Meeting dated 27th November 2017

86.1

The minutes of the meeting were agreed as an accurate record. Action: minutes to be signed and ratified

87 Matters Arising 27th November 2017

87.1 Item No. 75 Finance Report Month 7 An action plan to be formulated to address the worsening IAPT position and shared at the December meeting. Dr Gingell informed the Committee that Mrs O’Sullivan was formulating an IAPT plan to bring to future committee meetings. Mr Chamberlain informed the Committee that Walsall had requested an action plan that they could sign up to. Dudley has invested in IAPT. Dr Gingell advised that previously additional scrutiny would have been in place which is now required to be implemented. Comments around ‘muddled delivery in primary care’ due to lack of capacity. Dr Weaver highlighted the enormous amount of people that were being referred through Dudley. Mr Chamberlain highlighted that a lot of highly qualified staff were doing low level activities and he was working on an action plan with Mrs Lesley Burton. Dr Gingell suggested Mrs Burton and Mrs AM Carey should look into this and present to this committee at the next meeting in January. Action – action plan for IAPT position carried forward to January 2018 – invitation to Mrs Burton and Mrs Carey for January F&P meeting.

Mrs L Burton/ Mrs A M Carey

87.2 Item No. 77 PbR and Clustering Future reports to be on an exception basis highlighting those teams that were not achieving targets set. Mr Lancaster queried why this was ‘red’ action Item to be carried forward.

Completed/closed Agenda item

87.3 Item 78.2 CIP report Remove the CIP report as a standing agenda item for remainder of the year. Action – to communicate to team that the CIP report

Completed/closed Taken off agenda initially but added back on following V Moore forwarding CIP report. Mr Banks


should be as and when for future meetings

87.4 Item 78.4 Income and activity Month 7 Update on capacity issues taken to December meeting and whether to pass to the Q&S committee for review regarding safety. Mr Banks explained that Mrs Cooper had reported at the last meeting – and had not any further causes for concern. Action – to carry forward and highlight any other issues if appropriate. Dr Gingell – queried why this was on the action list as there will always be a capacity issue and suggested this be put on Q&S Committee as a standing item with clear criteria of what is over and above the ‘norm’ providing an accurate exception report. Dr Weaver highlighted the impact of the bed manager but her impact is limited as reliant on more senior staff members to implement changes. Action – Dr Iqbal, bed manager and Mrs Cooper to produce a report highlighting the ‘norm’ regarding bed capacity and over and above the norm on a quarterly basis.

Agenda item Dr Gingell

87.5 Item 78.5 Contractual Delivery against service lines December meeting highlight progress made on negotiations for 2018-19 Mr Chamberlain explained in Mr Parker’s absence that offers had gone out to the non-hosts. Growth of half a million pounds generated. Dudley taken an unusual approach re. return for MCP requesting detailed budgets and forecasts. Service line reporting would be produced in future. Walsall – original proposal was growth of 2.5 million related to quips that have not delivered. Mr Lancaster queried the timescale set which was previously set for end of December but now it appears that this has been extended to end of January 2018. Additional income expected is £2 million and this will contribute to the CIP shortfall. This would go to the Trust Board/MExT meeting and was discussed briefly at Exec Comms this morning. Action – briefing paper to be presented – Mr Chamberlain to produce this and present to committees.re. contract update for January 2018.

Agenda item Mr Chamberlain


87.6 All other items were either completed or had a future completion date.

88 PERFORMANCE (item 5.0)

88.1 Performance Report – Month 8 (item 5.1) Mr Banks In Mr Singh’s absence, Mr Banks highlighted the overall

position on page 3 – 6% above contractual target increased slightly on previous month. KPI’s quarter 3 thresholds regarding 5 areas that are below target and talked through the detail within the report. Slide 4 provides further analysis. Data very comparable to previous month. Mr Lancaster concerned that no executive was held accountable for the KPI not performing. There were financial implications for under performance and commissioners could request recovery plans. Mrs Gingell concerned regarding capacity at executive level. 13 re-admissions comparable to prior months – other data was consistent with previous months.

89 PbR REPORT AND CLUSTERING PERFORMANCE DISCUSSION (item 6)

Mr Byng

89.1 Mr Byng was not currently present. Item to be discussed later in the meeting. Mr Byng entered the meeting at 11.30am – slides 4 and 5 were highlighted but no significant variances from previous reports. Page 7 was highlighted to the committee. Mr Byng had no concerns except that the positive performance could be maintained longer-term. Dr Weaver highlighted the positive impact of having a cluster champion in areas. Thanks noted to Lynne Healey and Minoga Kamal for working over and above in the areas discussed. Mr Byng left the meeting at 11.45am.

90 FINANCE (item 7.1) MONTH 8

Mr Banks

90.1 Mr Banks highlighted the key messages and current performance slide was noted regarding £1.32m surplus £53k above plan. £53k variance split between pay and non-pay. Other areas from the report were highlighted to the Committee. Agency costs were significantly down on previous years.


Agency spend £330k target a month £338k actual. Income position is favourable and continues to be down against contract mainly around detox beds. Page 5 Trust summary I&E was highlighted to Committee – pressure areas were around corporate areas. Page 6 regarding contractual income deficit of £14k – improvements were noted on previous months. Over performance was highlighted across the CCG’s. Slide 7 regarding service line position. Key areas highlighted to the committee. Telephony and network costs were significantly higher than forecast. Finance team to investigate reasons why this was the case. Action – analyse reasons for high expense for telephony and network compared to previous year Slide 8 was discussed and narratives provided to any key variances. Page 9 provides an overview of forecast improving from £122k to £70k and anticipation that this would continue to fall. £1.8m surplus is likely to be achieved at year-end. Dr Gingell questioned if there is a plan to spend any surplus cash. Quality of service was deemed a priority regarding capital programme. Mr Lancaster asked for clarification on Step down beds and Dr Weaver explained that this was related to a patient who requires less intensive care than previously required at admission. Pages 12-14 details agency expenditure. More details were now required to be produced by the finance team in this area. Main capital expense was related to Bushey Fields refurbishment.

Mr Banks

91 Income and Activity Report – Month 8 (item 7.2)

Mr Banks

91.1 Mr Banks highlighted that headlines were picked up within the finance report.

Mr Byng entered the meeting at 11.30am

92 Contractual Delivery against Service Lines (item 7.3)

Mr Parker

92.1 Mr Parker was not present at the meeting.


Mr Banks highlighted that this had been discussed in previous items above.

93 CIP REPORT 93.1 Future CIP targets were briefly discussed. Felt this was a

significant task to undertake. Future schemes and targets were a challenge going forward. Action – control checks and CIP targets for 2018 to be brought to the January 2018 meeting. Dr Weaver queried whether CIP targets across the 3 Trusts were comparable. Mr Chamberlain was not aware that this was the case.

Mr Banks

94 Any Other Business (item 8.0) All

94.1 No other business noted.

95 Date, Time and Venue of Next Meeting (item 9.0)

95.1 Monday 22nd January 2018 14:00 to 17:00 hours Board Room, Canalside House, Walsall

END TIME: 11.50 HOURS


Board Meeting date: 1 February 2018


Finance Report Month 9 – 2017/18

2017/18 DWMHPT Finance Report Month 09 Page

• Key Messages: Current Performance 1

• Single Oversight Framework (NHS Improvement) 2

• Overall Summary and RAG Assessment 3-4

• Trust Summary Income & Expenditure Statement: Functional Analysis 5-8

• Cost Improvement Programme 9

• Agency Cap / Agency Spend by Staff Group / Reported Shift Breaches (weekly) 10-12

• Capital Programme 13

• Payables Performance & Aged Debt 14

• Cash Flow Statement 15

• Statement of Financial Position (Balance Sheet) 16

Key Messages : Current Performance

Financial Position £1,408k surplus at M09 £13k Favourable variance

• The Trust has delivered a month 9 surplus of £1,408k.

• This represents a favourable variance of £13k against the planned Year To Date surplus of £1,395k.

Expenditure – Pay £81k Favourable variance

• Pay expenditure is £81k in surplus against budget to date, which has been driven by vacancies across the Trust.

• Bank & Agency spend equates to £511k in month (split £326k for Agency and £185k for Bank) which is up on the previous month’s spend of £500k (split £338k for Agency and £162k for Bank).

• Agency spend is still currently ahead of plan by £139k in relation to the overall £4.05m Agency target for the year (actual spend of £2,921k against £3,061k plan).

Expenditure – Non Pay

£219k Adverse variance

• Non-Pay expenditure is £219k in deficit against budget to date:

• £407k of this is driven by over-spending by budget holders against their non-pay lines and non delivered devolved CIP.

• Offset in part by a surplus on budget reserves of £370k less non-delivered CIP held centrally of £169k.

Income & Activity– 2017/18 outturn

£151k Favourable variance (incl £405k contracted activity over-performance)

• The Trustwide Contracted Activity position at month end is reflecting an over-performance of £405k and is explained as:

• Walsall CCG reflects the expected reinstatement of funds in relation to Complex Care team and QUIPP schemes (both £230k each to date) and is showing an over-performance therefore of £461k.

• Other smaller CCG contracts in total (such as Worcester) have under-performed by £2k

• Non Contract Activities have over-performed against plan by £74k

• The activity in the Detox beds at Bushey Fields has under performed by £71k

• Non-contracted Income such as SLA’s and Education Income has reduced in month due to the release of £342k of pass-through funds due to Local Workforce Action Board Health Education England and this has deflated the current over-performance in contracted income mentioned above, giving an overall favourable income position for the year to date of £151k (which includes Interest Receivable shortfall of £1k).

CIP plans delivered for 2017/18

£3,371k delivered against target

• In order to meet in year cost pressures the Trust has identified CIP schemes equating to £3,776k.

• At month 9 schemes have delivered £3,371k.

• The four schemes held centrally are being phased into the finance position each month (£105.6k Full Year Effect) and could be deemed to being met non-recurrently through the overall favourable (surplus) finance position to date.

• Executive focus is particularly on those schemes rated as red.

Expenditure - Capital

£1,525k spend YTD

• The Capital Programme has been agreed at £3.8m for the year; a recent review undertaken by the Director of Finance indicates that spend will be £2.9m.

• At month 9 £1,525k has been spent to date. Outstanding expenditure particularly relates to Clee Ward and replacement bedroom doors for DPH .

1

Single Oversight Framework – Trust Performance

Commentary

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

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

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

mandate tailored support as appropriate.

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

• Current month position and position for the Trust to date is giving a maximum rating of 1.

2

Q1 Q2 M07 M08 M09 Forecast Outturn

subcode Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual

Liquidity Rating PRR0170 1 1 1 1 1 1 1 1 1 1 1 1 Capital Service Cover Rating

PRR0160 1 1 1 1 1 1 1 1 1 1 1 1

I&E Margin Rating PRR0180 1 1 1 1 1 1 1 1 1 1 1 1

Distance from Financial Plan

PRR0190 1 1 1 1 1 2

Agency Rating PRR0200 1 1 1 1 1 1 1 1 1 1 1 1

Overall Use of Resources

PRR0220 1 1 1 1 1 1 1 1 1 1 1 1

Overall Summary and RAG Assessment

Commentary

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

of £1.839m, as per the agreed Control total with NHSI.

• As at month 9 the Trust has delivered a surplus of £1,408k, which is £13k ahead of plan.

• Total Income is reflecting an over-recovery of £151k year to date (net of Interest Receivable) which includes a current level of over-performing contracted income with CCG’s of £405k

CIP 2017/18 Delivery • The Trust has declared an internal plan of £3,776k for 2017/18

and has schemes in place totalling £3,765k.

• At month 9 there is a balance of £106k non-delivered CIP held centrally. It is important that this balance is addressed on a recurring basis.

3

Statement of Comprehensive Income - Financial Position to 31st December 2017 Annual In Month Year To Date Plan Plan Actual Variance Plan Actual Variance

Income £000 £000 £000 £000 £000 £000 £000 Revenue From Activities Revenue-NHS Clinical 60,777 5,029 5,455 426 45,598 46,071 473 Revenue-Non NHS Clinical 923 105 41 (64) 599 526 (72) Total Revenue From Activities 61,700 5,133 5,496 362 46,196 46,597 400 Other Operating Revenue Revenue-Employee Benefits 696 56 85 29 529 613 83 Revenue-Education & Training 1,939 157 (187) (344) 1,632 1,302 (330) Revenue NHS Non-Clinical 1,442 119 68 (51) 1,111 1,088 (23) Other Revenue 556 44 68 24 425 445 20 Total Other Operating Revenue 4,633 376 33 (342) 3,698 3,447 (249) Total Revenue 66,334 5,508 5,529 20 49,893 50,046 151 Expenditure Pay (51,605) (4,339) (4,384) (45) (38,458) (38,377) 81 Non Pay (10,464) (826) (363) 463 (8,025) (8,432) (407) Trustwide Reserves 129 6 (495) (501) (98) (38) 60 Total Operating Expenditure (61,938) (5,156) (5,242) (83) (46,583) (46,847) (266) EBITDA 4,396 349 287 (62) 3,311 3,200 (114) Depreciation (1,475) (123) (107) 16 (1,106) (943) 163 Amortisation (256) (21) (34) (13) (192) (275) (84) Net Operating Surplus 2,665 205 146 (60) 2,013 1,982 (36) PDC (865) (72) (60) 12 (649) (601) 47 Interest Receivable 40 3 11 8 30 29 (1) P/L Disposal 0 0 0 0 0 0 0 Net Surplus /(Deficit) 1,839 136 96 (40) 1,395 1,408 13

Technical Adj - Impairment 0 0 0 0 0 0 0 Technical Surplus 1,839 136 96 (40) 1,395 1,408 13

Overall Summary and RAG Assessment Continued

4

4,778

3,765

2,500

0 1,000 2,000 3,000 4,000 5,000 6,000

Identified Schemes(FYE)

Identified Schemes(PYE)

CIP Target as perNHS Improvement

£'000

CIP 2017/18

1,839

1,408

0

250

500

750

1,000

1,250

1,500

1,750

2,000

£'00

0

Run Rate 2017/18

CumulativePlanned RunRate (Surplus)

Actual RunRate

3,800

1,525

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

£'00

0

Capital Programme 2017/18

PlannedSpend

RevisedPlannedSpend

CumulativeActualSpend

14,000

14,500

15,000

15,500

16,000

16,500

17,000

17,500

18,000

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

£'00

0

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18Revised Plan 14,047 15,304 15,575 16,073 16,416 16,169 16,288 16,530 16,746 16,597 16,261 15,402

Original Plan 14,697 14,682 14,702 14,985 14,966 14,531 14,862 14,887 14,885 15,210 15,230 14,791

Actual 16,161 16,501 15,674 16,220 16,643 16,556 17,185 17,225 17,589

Forecast vs Actual Cash Balance 2017/18

Trust Summary Income & Expenditure Statement Including Functional Analysis

Commentary

• The Trust is showing a £405k over-performance position against contracted activity levels. This is due to over-recovery on Non-Contract Activity and reinstatement of QIPPs to date coupled with a shortfall against Detox bed activity.

• Corporate areas have overspent in month due to additional costs incurred in relation to TCT staffing support, Telephone charges, E-Rostering and Membership fees.

• Central Reserves have deteriorated in the month due to transfer of income to STP in relation of training allocations. There still remains a balance of £106k CIP still to be devolved/delivered and this adversely impacts on the position.

• The Access service in-month underspend relates to vacancy savings in MHAS and Primary Care

• The Inpatients overspend in-month mainly relates to overspends on wards (£37k), plus non-delivery of the CIP target (£19k), net of psychology, ECT and HTT vacancies. The ward overspend includes the cost of £16k special observations for new stepdown patients.

• Community areas have seen a deterioration in month around the continued expectation of increased property rentals within Estates. This is driving the Year To Date and expected Final Outurn position.

• EI continues to reflect slippages around CAMHs funding received from Commissioners.

• Medical services have an underspend in-month, Year To Date and forecast for year end, as less of the locum budget has been required this year than in previous years (due to less vacancies, sick leave and maternity leave).

• The Trust is currently reflecting a surplus position of £13k ahead of the trajectory to deliver the £1.839m planned surplus at year end.

5

Annual Plan In Month Year to Date FOT M09

2017/18 Plan Actual Var Plan Actual Var Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS Revenue-Activities 61,277 5,069 5,496 427 45,973 46,445 472 (100) Revenue from LAs 864 100 93 (7) 554 487 (67) (97) Total Revenue from Activities 62,141 5,170 5,589 420 46,527 46,932 405 (197) Corporate Functions Corporate Departments (13,577) (1,121) (1,152) (31) (10,248) (10,705) (457) (621) Central Reserves 129 6 (495) (501) (98) (38) 60 850 Total Corporate Functions (13,448) (1,114) (1,646) (532) (10,346) (10,743) (397) 229 Operational Services Urgent Care & Access (5,446) (447) (434) 13 (4,083) (4,036) 47 33 Hospital Support (604) (50) (47) 3 (453) (451) 2 9 Inpatient Services (Acute & OA) (11,839) (987) (1,026) (39) (8,842) (9,165) (323) (419) Community Services (8,146) (714) (726) (13) (6,046) (6,116) (70) (95) Early Intervention (6,231) (517) (449) 69 (4,680) (4,553) 127 (50) Medical Services (12,034) (992) (974) 17 (8,768) (8,670) 98 300 Total Operational Services (44,301) (3,708) (3,657) 51 (32,871) (32,991) (120) (222) Total Expenditure (57,748) (4,822) (5,303) (482) (43,217) (43,734) (517) 7 Sub Total 4,393 348 286 (62) 3,311 3,199 (112) (190) Interest Receivable 40 3 11 8 30 29 (1) (12) PDC Dividend (865) (72) (60) 12 (649) (601) 47 102 Depreciation (1,729) (144) (141) 3 (1,296) (1,218) 78 100 Net Surplus/(Deficit) 1,839 136 96 (40) 1,395 1,408 13 0

Trust Income Statement – Income

Commentary

• The Trust is now operating on a block contract with Dudley CCG and Walsall CCG across all service lines.

• Also, this month, there have been additional adjustments in relation to:

• Dudley CCG – impact of 2016/17 CQUIN settlement of £57k; and

• Walsall CCG – 50% reinstatement of Complex Care and QIPP of £461.2k

• In patient detox service at Bushey Fields Hospital is currently £71k under-performing against the annual target.

• Overall the Trust is over-performing by £405k against its target to date.

• If the Trust were to report actual activity undertaken under a ‘shadow’ reporting arrangement then the Trust would actually be over-performing by £911.1k (was reported as £1,105.4k in month 8)

• This level of over-performance would primarily be reflected as:

• Walsall CCG £452.6k over

• Dudley CCG £266.6k over

• Sandwell & West Birmingham CCG £247.2k over

• Wolverhampton CCG £46.8k over

• Birmingham Cross City CCG £57.0k over

• Remaining CCGs £34.7k under

• = Total CCG over-performance of £1,035.4k

• Offset by Non-Contract Activities and Detox beds mentioned earlier

6

Annual Plan In Month Year to Date FOT M09


Revenue From NHS Activities Dudley CCG 28,215 2,351 2,313 (38) 21,162 21,157 (4) 0 Walsall CCG 27,195 2,230 2,691 461 20,413 20,874 461 0

Sandwell & West Birmingham CCG 1,894 158 161 3 1,421 1,435 14 0 Wolverhampton CCG 338 28 29 1 254 261 7 0

Birmingham Cross City CCG 498 42 46 4 374 382 8 0 Birmingham South Central CCG 29 2 5 2 22 47 25 0

South East Staffs & Seisdon CCG 144 12 12 0 108 108 1 0 Stafford & Surrounds & E Staffs CCGs 2 0 0 0 1 5 4 0

Cannock Chase CCG 142 12 12 0 107 115 9 0 East Staffs CCG 4 0 0 0 3 3 0 0

Redditch & Bromsgrove CCG 17 1 2 0 13 13 (0) 0 Wyre Forrest CCG 33 3 4 2 25 28 3 0

NHS South Worcester CCG 2 0 (0) (0) 1 4 2 0 NCA - Adult Neuro 422 35 36 1 314 371 57 0

Income Generation CIP 0 0 0 0 0 0 0 0 NCAs 442 37 26 (11) 331 217 (114) (100)

CAMHs Deaf 1,401 117 117 0 1,051 1,051 0 0 Total NHS Revenue-Activities 60,777 5,028 5,454 427 45,598 46,070 472 (100)

Revenue - Local Authorities

Walsall MBC 0 0 0 0 0 0 0 0 Dudley MBC 680 85 85 (0) 416 416 0 0

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

Stafford MBC 0 0 0 0 0 0 0 0 Detox Beds 184 15 8 (7) 138 66 (71) (97) Dudley CRI 0 0 0 0 0 0 0 0

NCA - Other HC 0 0 1 1 0 4 4 0 Total Revenue from LAs 864 100 93 (7) 554 487 (67) (97)

STF Funding Income - DoH 500 42 42 0 375 375 0 0

Total Revenue from Activies 62,141 5,170 5,589 420 46,527 46,932 405 (197)

Trust Income & Expenditure Statement - Corporate Functions

Commentary

• Chief Executive – We now have 3 staff members who have been aligned with the TCT workstream which is a significant cost pressure. Other pressures relate to costs for the IAPT review and investigative costs. L&D continues to support the position with vacancy slippage.

• Corporate Affairs – Trust legal costs for the trusts are significantly more

than the budget probably due to additional work related to TCT. • Corporate HR – Agency costs associated with the DBS project, Occ Health

consultancy costs along with no progress on the Apprentice CIP so far. Investigative costs are also a factor in year. Benefit from TCT transfer of costs.

• Corporate Medical – YTD Agency usage within Pharmacy due to maternity and backfill.

• Corporate Estates – Water Maintenance has become more prominent

again within the trust and as such we are expecting increasing levels of testing therefore increased costs.

• Acute Estates – Utility costs continue to be low but are expecting them to

increase over the winter period. • Corporate Operations – E-rostering project costs , s.75 income deficiency,

reallocation of budget to Acute and the non-recurrent cost pressure of an additional Head of Service are the drivers behind the position

• Corporate Finance – Membership Cost pressures reduced in the month

resulting in a upturn in month. • Corporate IT/Performance – Telephony costs are being reviewed and we

are hoping this will result in a benefit. Agency costs of backfill will be continuing.

7

Annual

Plan In Month Year to Date FOT M09


Corporate Functions

Chief Executive (986) (82) (102) (21) (740) (903) (162) (165) Corporate Affairs (497) (43) (48) (6) (369) (400) (31) (20)

Corporate Human Resources & Dev. & People (1,139) (95) (82) 13 (854) (834) 20 (25)

Corporate Medical (1,145) (97) (95) 1 (855) (873) (17) (10) Estates - Acute (1,617) (136) (132) 4 (1,209) (1,167) 42 50

Estates - Corporate (1,268) (102) (127) (25) (963) (984) (21) (55) Corporate Operations (3,366) (274) (296) (23) (2,544) (2,727) (182) (231)

Corporate Finance (1,159) (99) (85) 14 (895) (956) (61) (60) Corporate Performance & IT (2,399) (194) (184) 10 (1,817) (1,861) (45) (105) Total Corporate Functions (13,577) (1,121) (1,152) (31) (10,248) (10,705) (457) (621)

Trust Income & Expenditure Statement - Operational Services

Commentary

• The Access service in-month underspend relates to vacancy savings in MHAS and Primary Care

• The Inpatients overspend in-month mainly relates to overspends on wards (£37k), plus non-delivery of the CIP target (£19k), net of psychology, ECT and HTT vacancies. The ward overspend includes the cost of £16k special observations for new stepdown patients.

• Medical services have an underspend in-month, Year to Date and forecast for year end, as less of the locum budget has been required this year than in previous years (due to less vacancies, sick leave and maternity leave).

• Community Estates – Impact of the anticipated additional costs for NHS Property Service buildings - we anticipate the additional cost to be in the region of £200k.

• Community Services & Recovery – CRS and Complex Recovery are showing underspends in the month which should subside as people move into posts.

• Community Management – The old year CIP element has now been transacted and we remain with the NP Travel CIP of £49k to be met.

• EI – Continued usage of agency within CAMHS is supporting the prolonged WLI program. Position improved in month due to outstanding invoices being raised for services.

8

Annual

Plan In Month Year to Date FOT M09


Operational Services

Urgent Care & Access (5,446) (447) (434) 13 (4,083) (4,036) 47 42

Hospital Support (604) (50) (47) 3 (453) (451) 2 0

Inpatient Services (Acute &

OA) (11,839) (987) (1,026) (39) (8,842) (9,165) (323) (419)

Community Services Community Estates (546) (45) (64) (18) (409) (562) (153) (200)

Community Management (CIP) 19 1 (0) (1) 16 7 (9) (35) Community & Recovery

Services (7,620) (669) (663) 7 (5,652) (5,561) 92 140

Total Community Services (8,146) (714) (726) (13) (6,046) (6,116) (70) (95)

Early Intervention (6,231) (517) (449) 69 (4,680) (4,553) 127 (50)

Medical Services (12,034) (992) (974) 17 (8,768) (8,670) 98 300

Total Operational Services (44,301) (3,708) (3,657) 51 (32,871) (32,991) (120) (222)

Cost Improvement Programme

Commentary

• The Trust had initially declared a plan to NHSI of £2,500k in order to deliver the planned surplus of £1,839k

• However, internally in order to deliver the required plan in year (meeting requirements around cost pressures) the Trust has had to identify CIP schemes of £3,776k

• In total 19 separate schemes have been identified in order to deliver the £3,776k CIP target.

• The table opposite identifies these schemes and the current expectations and performance to date.

• At the beginning of the new financial year all but four schemes had been fully devolved down to service lines. CIP schemes 12, 14 and 18 in relation to vacancies have now all but been delivered, with a total of £106k remaining against central funds.

• This is effectively the balance of scheme CIP01 at £55.4k plus a residual balance on the three vacancy CIPs mentioned above, still to be delivered.

• As of Month 9 a total of £3,370k has been delivered out of the overall £3,776k target.

9

Annual Of Which Schemes CIP Delivery to Date Likely

Achievement Recurrent 17/18

Cost Improvement Programmes (by POD) Ref Plan

Devolved to Service Lines

Still Held Centrally Achieved Outstanding

(excl. mitigations)

Plans Outstanding

Current RAG

£ £ £ £ £ 4 Step Down Beds from DGoH CIP001-17 178,500 123.117 55,383 123,117 55,383 123,117 178,500 Walsall QIPP Access Pathway (Urgent Care) CIP002-17 75,000 75,000 0 75,000 0 75,000 35,648 Dudley Primary Care & IAPT Decommissioning CIP003-17 200,000 200,000 0 200,000 0 200,000 - Operational Budget Reserves CIP004-17 150,000 150,000 0 150,000 0 150,000 - Increase NCAs CIP005-17 200,000 200,000 0 185,209 14,791 200,000 - Corporate Operations CIP006-17 170,000 170,000 0 168,879 1,121 170,000 1,121 Shift Pattern review CIP007-17 125,000 125,000 0 10,118 114,882 10,118 114,882 Estates Review CIP008-17 50,000 50,000 0 0 50,000 50,000 50,000 Efficient Recovery Pathway Review CIP009-17 125,000 125,000 0 125,002 -2 125,002 29,104 MEA Revaluation of Fixed Assets CIP010-17 400,000 400,000 0 399,895 105 400,000 400,000 Inflation Topslice CIP011-17 125,000 125,000 0 125,000 0 125,000 - Vacancy Review CIP012-17 200,000 0 200,000 301,281 -101,281 301,281 - Apprenticeship Levy CIP013-17 60,000 60,000 0 0 60,000 - 60,000 TCT Back Office Review CIP014-17 50,000 0 50,000 54,000 -4,000 54,000 - Non Recurrent Savings CIP015-17 500,000 500,000 0 500,000 0 500,000 500,000 Non Pay Review (Travel savings) CIP016-17 100,000 100,000 0 34,982 65,018 100,000 - Budgetary Reserves CIP017-17 500,000 500,000 0 500,000 0 500,000 -

Casual Vacancy Deductions (Non Recurrent) CIP018-17 500,000 0 500,000 361,972 138,028 361,972 500,000 Walsall Carers Service CIP019-17 56,250 56,250 0 56,251 -1 56,251 - Total CIPs 3,764,750 2,959,367 805,383 3,370,706 394,044 3,501,741 1,869,255 Annual Target 17/18 3,776,246 3,776,246 (Deficit) / Excess of Schemes Above Plan -11,496 -274,505

NHS Improvement – Agency Expenditure Cap 17/18

Commentary

• For 2017/18 the Trust has been tasked with working within an overall agency expenditure cap of £4.05m for the year,.

• The planned spend across the year has been profiled across the new service lines based on the spend patterns from the previous year with an assumed level of reduction in spend in order to meet the required cap.

• The Trust has also been tasked with further reducing its Medical Locum spending by £86,760 in year in order to support the national drive to reduce locum spending – this expectation is embedded within the £4.05m cap but will be monitored against last financial years Medical Locum spend of £1.284m.

• If the Trust is able to work within the Medical Locum spend plan of £1.1m it will more than deliver the required spending reduction expected.

• In month the Trust has spent £326k on Agency (down from £338k last month) and Year to Date the spend equates to £2,921k, which is below the planned spend position and is therefore £139k ahead of the cap.

• Comparison to the same period last financial year shows that we are £595k lower in terms of spend (16/17 spend at M09 of £3,516k compared to current year spend of £2,921k)

10

Agency Analysis 17/18 - Performance by Service Line

Annual Profile Agency Agency Distance

Service Line To Meet Cap Actuals M1-M9 Plan M1-M9 from Target £000s £000s £000s £000s

Urgent Care & Access £504 £414 £381 -£33

InPatient Services £1,046 £669 £793 £124

£1,550 £1,083 £1,174 £91 surplus to plan

Community Services £66 £76 £50 -£26

Early Intervention £1,034 £543 £779 £236

£1,100 £619 £829 £210 surplus to plan

Dudley Medical £540 £360 £408 £48

Walsall Medical £560 £595 £423 -£172

£1,100 £954 £831 -£123 deficit to plan

Corp IT Services £4 £19 £3 -£16

Corporate Affairs £11 £0 £9 £9

Corporate Estates £98 £83 £74 -£9

Corporate Operations £61 £74 £46 -£28

Corporate-CEO £26 £15 £19 £4

Corporate-Finance £11 £23 £8 -£15

Corporate-HR £32 £31 £24 -£7

Corporate-Medical £10 £43 £8 -£35

Corporate-Performance £48 £27 £36 £9

Corporate-Reserves £0 -£50 £0 £50

£300 £265 £227 -£38 deficit to plan

Grand Total £4,050 £2,921 £3,061 £139 surplus to plan

for 2017/18 there is an embedded expectation that Medical locum spending would reduce compared to 2016/17 levels in order

to support the national delivery of a £150m Medical locum reduction.

For the Trust we have been tasked with reducing our Medical locum spend by £86,760 over our 2016/17 levels of £1.284m

The 'plan' above of £1.1m would ensure that this target is fully achieved

Agency Spend by Staff Group

Commentary

• This view of the agency spending looks at the staff groups categories that are reported to NHSI on a monthly basis.

• A further breakdown is provided around the ‘other’ staff category which identifies the main service line / budget areas that contribute to this category.

• As experienced last financial year some of the spending in month has been the result of additional support needed to cover areas such as:

• 1-2-1 observations

• Support for one-off project works, such as E-rostering and Water Management

• Delivery of in year waiting list schemes funded non-recurrently by commissioners, for example, CAMHs.

• These additional costs will continue to be a pressure to the Trust in terms of delivery against the agency cap target.

11

In Mth (£000) Year End (£000)

Plan Act Variance Plan Act Variance

Agency Staffing

Qualified Nursing £120 £118 £2 £1,050 £1,070 -£20

Medical £87 £87 -£0 £711 £912 -£201

Other (Incl. Admin, Estates, HCA's , AHP's) £151 £121 £30 £1,299 £939 £360

£358 £326 £32 £3,060 £2,921 £139

Other' represented by:

Unqualified Nursing £34 £140 note 1

Admin & Clerical / Maint & Works £44 £380 note 2

Scientific & Technical £43 £419 note 3

£121 £939

note 1 note 2 note 3

Malvern £17.4 Estates £83.4 Walsall CAMHs £80.8

Wrekin £6.7 E-Rostering £74.0 Dudley CAMHs £54.4

Clent £9.8 IM&T £45.9 Dudley Primary Care -£8.9

Kinver £16.9 DPH / BF Med Secs £43.9 OA In-Pats / OT £139.3

Langdale £18.7 Finance / HR / PA's £64.2 Adult In-Pats £16.9

Cedars £15.9 ANS £1.4 Criminal Justice £25.1

Linden £20.3 Walsall IAPT £18.7 Dudley EI £65.1

Ambleside £30.0 Walsall CAMHs £9.3 Walsall EI -£0.7

Holyrood £52.8 Dudley CAMHs £21.9 Walsall Primary Care -£0.7

Birch Day £0.2 Dudley Primary Care £7.4 OA CMHT £40.4

Dudley Access £4.4 Dudley CRS -£2.8 Dudley Access £7.6

Old Year Accruals w/o -£53.3 Dudley IAPT £12.3

£139.9 £379.7 £419.3

Agency – Reported Shift Breaches to NHSI (weekly)

Commentary

• The above graph represents both the total number of Agency shifts booked as well of the proportion of shifts that have breached the NHSI prescribed price caps (in terms of agency staff who are charging hourly prices above the mandated agency cap rates).

• This represents the level of total shifts reported each week to NHSI as part of the revised agency returns – this gives some indication therefore of the level of breaches as compared to total shifts worked.

• The rise in terms of shifts booked during August to September was representative of the increased levels of special observations and patient acuity experienced at that time.

• Reporting is reflective of staff groups as per TFIMS headings – Medics do not appear on this analysis as they are covered under StaffFlow which ensures that agencies used and rates paid are in line with the mandated agency rules. 12

0

10

20

30

40

No

of S

hift

s

03-Apr

10-Apr

17-Apr

24-Apr

01-May

08-May

15-May

22-May

29-May

05-Jun

12-Jun

19-Jun

26-Jun 03-Jul 10-Jul 17-Jul 24-Jul 31-Jul 07-

Aug14-Aug

21-Aug

28-Aug

04-Sep

11-Sep

18-Sep

25-Sep

02-Oct

09-Oct

16-Oct

23-Oct

30-Oct

06-Nov

13-Nov

20-Nov

27-Nov

04-Dec

11-Dec

18-Dec

25-Dec

Medical (Price) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Nursing (Price) 24 21 19 16 25 26 25 25 25 24 26 24 16 16 19 19 19 19 11 11 11 11 11 11 11 11 11 10 10 13 13 13 13 6 6 6 6 11 11

HCAs (Price) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Admin & Estates (Price) 6 6 5 5 5 5 5 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0

ST&T / AHPs (Price) 17 18 16 16 17 15 16 18 17 15 17 17 16 16 16 16 16 9 16 16 17 15 14 13 16 17 17 18 18 15 14 15 15 13 12 12 14 14 14

Total Shifts Booked 238 212 186 204 219 195 207 216 225 215 212 219 251 260 284 284 274 299 266 292 304 305 308 281 283 285 295 276 283 289 304 294 274 261 274 273 287 307 350

No of Shift Breaches by Week/Staff Group (out of total shifts booked above)

Total Weekly Agency Shifts Booked

180190200210220230240250260270280290300310

Capital Programme

13

Commentary

• The budget for the Clinical Systems Development has been reduced in year by £1,700k. £1,200k of this has been used to fund additional Estates projects and to create a contingency for further capital works that may be required in year. The remaining £500k will be taken off the Trust’s CRL for this financial year, as discussed at ECPG in June 2017.

• The budget for the Clinical Systems Development has been reduced further at month 9 to £100k. £400k of the reduction has been used to reduce the Trust’s CRL for the year to £2,900k. The remaining £200k will be used to fund other capital schemes including implementation of the IAPTUS system and purchase of a Transcranial Magnetic Simulation Machine.

Payables Performance & Aged Debt

Commentary on Payables

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

achieved the target for the Year to Date (YTD). In terms of value then whilst the target has not been achieved in month the YTD position does still reflect full achievement.

• In terms of the NHS target there has been a full delivery against both Value and Number within the current month. In terms of YTD the Number metrics has been achieved whereas the Value metrics has not.

• The NHS metrics can vary dramatically in terms of percentage achievement as the number of NHS invoices processed each month is on average around 30 invoices in total. Thus a delay in payment of 2 invoices will cause the percentage to drop below the required 95%.

Commentary on Aged Debt

Aged Debt Profile by Value • 35.0% of debt was aged 91 days or older at the end of the period equating to £411k in total, and this is explained by:

• Debt between 91-120 days (totalling £59) relates in the main to:

• Black Country Partnership £41.3k regarding Liaison & Diversion (L&D) Project Sep 2017

• Walsall Healthcare regarding OA Psych Liaison £14.0k Sep 2017

• Various CCG’s regarding NCAs £1.6k

• Walsall MBC £1.8k regarding Staff recharge Aug 2017

• Debt over 120 days old (totalling £352k) relates in the main to:

• Walsall Healthcare regarding Older Adults Psychiatric Liaison £42.0k Apr-Jun17

• Dudley CCG £257.5k regarding a combination of 2016/17 CQUIN settlement and IAPT

• Black Country Partnership £41.3k regarding L&D Project Aug17

• Various CCG’s regarding NCAs £11.9k

• Walsall MBC £1.3k regarding CAMHS staff recharge May 2017

14

Better Payment Practice Code

Agreed Tolerances Transactions by Number Value Non-NHS <75% 75% - 95% >95% Qtr 1 95.32% 98.02% Qtr 2 94.51% 97.63% Oct 88.85% 94.66% Nov 91.04% 98.51% Dec 95.00% 92.02% Non-NHS YTD 93.41% 96.78% NHS <75% 75% - 95% >95% Qtr 1 95.78% 93.54% Qtr 2 96.34% 94.80% Oct 92.50% 97.28% Nov 94.74% 91.39% Dec 95.83% 96.67% NHS YTD 95.90% 94.81%

37.1%

15.5% 12.4%

5.0%

30.0%

Aged Debt as of December 2017

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

Debt Profile and Value Current 31-60 days 61-90 days 91-120 days 121+ days Total

£000 £000 £000 £000 £000 £000 £437 £183 £146 £59 £352 £1,176

Aged Debt

Value % of Total

Agreed

Tolerances £000 Debt

Over 91 days >20% 10% - 20% <10% £411 35.0%

Over 120 days >10% 5% - 10% <5% £352 30.0%

Cash Flow Statement

15

Commentary

Cash Flow • The Trust has made an operating surplus of £1,977k in

2017/18 and received cash of £1,253k in respect of depreciation and amortisation

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

• Trade and Other Payables have decreased over the period (a negative impact on cash)

• The Trust has paid a Public Dividend Capital (PDC) dividend of £407k (made up of a cash payment of £393k and a reduction in PDC receivable of £14k)

• The Trust has received £29k of interest, and spent £1,714k on capital (including on reducing capital payables from the 2016/17 year end). Total capital expenditure in cash terms was less than the cash received for depreciation and amortisation (a positive impact on cash)

• The impact of all these movements was to increase the Trust’s cash balance Year to Date by £623k

Statement of Financial Position

16

Commentary

Non Current Assets • Expenditure exceeds amortisation and depreciation in the

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

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

Current Assets • Receivables have increased by £163k in 2017/18

• Cash is £623k higher than the balance at 31 March 2017

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

Current Liabilities • Payables have reduced by £256k in the financial year

• There has been a £54k reduction in the value of provisions held since the start of the year

Tax Payers’ Equity

• The Current Year I&E figure represents the surplus for the year to date of £1,403k

• This is £13k ahead of the plan for Month 9 2017/18


Agenda Item number: 8.1.2d

Enclosure: 13

Report Title: Cost Improvement Programme (CIP) Progress Report

– January 2018 Accountable Director: Rupert Davies, Interim Director of Finance, Performance, IM&T and

Estates Author (name & title): Jacky O’Sullivan, Clinical Development Director/Acting Associate

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

Improvement Programme for 2017/18. Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report Finance and Performance Committee, 22nd January 2018 MExT, 23rd January 2018 Key points or recommendations from Committee or Group: 21 schemes have now been identified in 2017/18 to achieve the CIP target of £3,778,000. Of these 21 schemes, 7 schemes have delivered, 10 schemes are expected to deliver their Part Year Effect, 2 schemes have been closed without delivery, and 2 schemes will not deliver the expected part year savings Strategic Objective(s) to which this paper relates:



Leadership culture




Quality Impact Assessment Domain Comment Patient Safety

Will be considered as part of the Quality Impact Assessment for each scheme

Patient Experience


Clinical Effectiveness / Outcomes


Workforce Experience – Efficiency & Productivity


Continuous Improvement in the Quality of Care


Enc 13 TB CIP Update Jan for Feb18v2 Page 1 of 15

The CQC domains that this report relates to are: Caring

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

Responsive

Plans are developed to ensure responsiveness to service user needs.

Effective

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

Well-led

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

Safe

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


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

Yes

Idea developed and presented to MExT MExT approve/reject

No Idea archived

Project Workbooks developed & submitted to CGI Programme Board for approval & sign off –

including QIA, EIA, PIA & risks

Implementation Stage

Final QIA and risks presented to MExT for project closure

Summary of schemes including Quality Impact Assessment (QIA) & risks submitted to MExT and

Trust Board

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

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

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

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

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

Idea archived No


Title Cost Improvement Programme (CIP) Progress Report

January 2018 Introduction The purpose of this report is to present to the Board a summary of the current status of the Cost Improvement Programme for 2017/18. Executive Summary of key points, issues, financial impact and risks 21 schemes have now been identified in 2017/18 to achieve the CIP target of £3,778,000. Of these 21 schemes, 7 schemes have delivered, 10 schemes are expected to deliver their PYE, 2 schemes have been closed without delivery, and 2 schemes will not deliver the expected part year savings. Key points, issues and risks 1.0 CIP 2016/17 2 schemes were carried over to 2017/18 (Appendix 1), these are: Dudley Older Adult Service Medical Services Establishment Review

The Dudley Older Adult Service scheme is dependent on the implementation of the new service model, which is on track expected to deliver in quarter 4, and the scheme has a completion date of March 2018. The Medical Services Establishment Review scheme delivered £200k recurrent savings in 2016/17; the remaining £150k is being delivered from income on the Adult Neurodevelopmental Service. The service has a monthly income target which is on plan and forecast to achieve the full year effect by March 2018. These schemes are being monitored by the CIP, Growth and Improvement Programme Board. 2.0 CIP 2017/18

£ Target for 2017/18 3,778,000 Full year value of identified schemes 4,778,000 Planned part year effect of identified schemes 3,764,750 There were a total of 19 schemes identified at the start of 2017/18. Two have been closed without delivery and two additional schemes have been opened to address the shortfall, bringing the total number of schemes to 21. 5 schemes have delivered their savings and are now closed. 2 schemes; Operational Budget Reserves and Dudley Primary Care and IAPT Decommissioning have delivered and were being reviewed for closure via MExT. MExT has advised that due to the red risks of the QIA, the IAPT Decommissioning will not been closed and will remain ‘delivered and being monitored’.


10 schemes are expected to deliver savings by March 2018. Of these, 6 are red RAG rated as they are expected to deliver their part year effect (PYE) savings but have not identified full year effect (FYE) savings recurrently. These schemes are: Vacancy Review MEA Fixed Asset Revaluation Efficient Recovery Pathway Review Corporate Operations Budget Walsall New Urgent Care Pathway Unassigned Scheme (alternative to CIP007-18)

Two schemes are not on track to delivery any savings:

• Estates Review A long term project is in place to deliver savings, which will deliver savings equivalent to the 2017/18 target. Additional savings will be allocated to the 2018/19 CIP delivery.

• Unassigned Scheme (alternative to CIP013-18) No alternative has been developed to deliver the savings not achieved by the Maximising the Apprenticeship Levy. The savings target will carry forward to 2018/19.

A full list of projects and detailed updates can be found in appendix 2. The CIP, Growth and Improvement Programme Board will be monitoring and tracking the progress of these schemes to report risks, and mitigations to the Finance and Performance Committee and the Board. 3.0 CIP/CRES 2018/19 The Trust has adopted BCHC’s process for approving Cost Improvement Projects for 2018/19. A series of ‘Gateways’ are scheduled during Quarter 3 and Quarter 4 2017/18 to develop and authorise the proposed projects. There are separate gateways for Mental Health and CAMHS. Mental Health As well as the Trust developing its own plans some development meetings have been held jointly with BCPFT to coproduce schemes that will, where appropriate, deliver efficiencies and savings across all mental health services. Schemes have been developed into Project Initiation Documents (PID) and were submitted to the TCT Mental Health Gateway meetings held on Monday 13th November and 4th December. CAMHS The TCT CAMHS Gateway meeting were held on 20th November and 21st December, where PIDs were presented. For all Gateway meetings, the PIDs were presented to a panel made up of Directors from the Integration Board across quality, finance, operations, workforce and transformation. Approved schemes will progress to Gateway 2 in February 2018, with delivery planned to start in April 2018.


Further detail (if required) Appendix 1 and 2 contain further details of the schemes. Recommendation Trust Board members are asked to note the contents of this report and receive it for information and assurance. Board action required As recommendation.


Appendix 1 – 2016/17 CIP schemes

Ref. Division Type Project Title Exec Lead

Balance to FYE Value

(£)

Implementation

Progress Report

Ove

rall

Proj

ect

Stat

us

Plan

Fina

nce

KPI

s

Ris

ks

QIA

CIP007-16 Operations Transformational Dudley Older Adult Service LW 67,390 R A R N/A A A

Implementation began in October with completion and delivery of CIP by March 2018.

CIP010-16 Medical Transformational Medical Services Review

MW / KG 150,000 A A G N/A G A

This is being achieved through income for the Adult Neurodevelopmental Service which is on target at month 8 and forecast to achieve the full amount by March 2018. Risks reviewed and changed to a rating of Green, with an overall RAG rating of Amber.


Appendix 2 – 2017/18 CIP schemes

1. Schemes - Not on track for a PYE delivery

Ref. Directorate Type Project Title Exec Lead

Finance

Recu

rren

t/

Non

Rec

urre

nt

Implementation RAG

Scheme value in year (£)

Planned FYE value (£)

Ove

rall

Proj

ect R

atin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

CIP008-17 Trust Wide Transactional Estates Review

RD 50,000 100,000 Rec A A R R A A

This scheme will review the Trust’s portfolio of properties across Dudley and Walsall with a view to minimising the use of leased properties and maximising the use of owned

properties. Income previously allocated to contribute to CIP has now been discounted. The FYE value is estimated to carry forward to the 2018/19 target; however the scheme

will deliver it’s savings during 2018.

CIP022-17 Trust Wide Transformational

Unassigned (alternative to CIP013-18)

AW 60,000 240,000 Rec R R R R - -

This scheme has been opened to scope the delivery of the shortfall of CIP003-17. As at December 2017 it remains without a plan to deliver it and a potential £240k may carry

forward to 2018/19


2. Schemes - In Progress and expected to deliver PYE


Finance

Recu

rren

t/

Non

Rec

urre

nt Implementation RAG

Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect R

atin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

CIP001-17 Operations Transformational Step Down Beds

LW 178,500 238,000 Rec A A A G A G

Income generation through the provision of step down beds. This scheme is now live, and is expected to meet its PYE, and FYE in subsequent years. If the full expected bed usage is realised the scheme could over perform by up to £77k per year.

CIP002-17 Operations Transformational Walsall New Urgent

Care Pathway

LW 75,000 150,000 Rec R R R R - -

Remodelling of the urgent care pathway in Walsall as part of a QIPP will potentially deliver this schemes target. Commissioner intentions of the future model are needed to progress the scheme. Due to delays with the commissioner, the PYE will be met through alternative savings. These will achieve the PYE target and contribute £95k to the FYE. £55k is estimated to carry forward to the 2018/19 target.

CIP005-17 Operations Transformational Increase in NCA

Activity

LW/RD 200,000 200,000 Rec A G G G A A

Income generation through non contracted activity. £100k has been transacted. The scheme is behind schedule, but is expected to deliver its target by March 2018.

CIP006-17 Operations Transactional Corporate Operations

Budget

LW 170,000 300,000 Rec R R G R G G

Savings to be realised from the Corporate Operations budget. The PYE value has been identified in vacancies, which will deliver recurrently. £131k is estimated to carry forward to 2018/19 targets. The Quality and Safety Committee approved the schedule of vacancies and received assurance that there are no risks or quality issues identified in removing these posts.

CIP009-17 Medical Transformational Efficient Recovery

Pathway Review MW 125,000 250,000 Rec R R G R - -




Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect R

atin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

Savings to be realised from reduction in activity and new service model. This project is expected to deliver in 2018/19. Alternative recurrent savings have been identified which meet the PYE value. £126k is estimated to carry forward to 2018/19 targets.

CIP010-

17 Trust Wide Transactional MEA Fixed Asset

Revaluation

RD 400,000 400,000 Rec R R G R G G

PDC savings and IT depreciation moving to 7 years. £400k has been delivered for the PYE non-recurrently. The scheme is unlikely to deliver recurrently, and an alternative project will be needed to deliver these savings in 2018/19.

CIP012-17 Trust Wide Transformational Vacancy Review

AW 200,000 400,000 Rec G G G G G G

Long term vacant posts will be assessed for continued requirement and removal. £301k has been transacted recurrently, which will deliver £334k FYE recurrently. £66k is estimated to carry forward to 2018/19 targets. The Quality and Safety Committee approved the schedule of vacancies and have received assurance that there are no risks or quality issues identified in removing these posts.

CIP016-17 Trust Wide Transactional Non Pay Review

RD 100,000 100,000 Rec G G G G G G

Deliver savings via a review of the travel expenditure. £35k has been transacted. Savings are being identified and this scheme is expected to deliver its target by March 2018.

CIP018-17 Trust Wide Transactional Casual Vacancy

Reduction RD/LW 500,000 500,000 Non Rec G G G G G G




Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect R

atin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

Non recurrent savings from vacancies. A review of vacancies is scheduled for January 2018. £362k has been transacted to date, and the scheme is expected to deliver its target by March 2018. The Quality and Safety Committee approved the schedule of vacancies and have received assurance that there are no risks or quality issues identified in removing these posts.

CIP021-17 Operations Transformational

Unassigned (alternative to CIP007-18)

RM 125,000 250,000 Rec R R R R - -

£10,000 of recurrent savings have been transacted. A further £128k has been identified to offset the shortfall of CIP007-17. Further work is ongoing to identify more savings, but a maximum of £112k is estimated to carry forward to 2018/19 targets.

Key: Scheme value in year non-recurrent Enc 13 TB CIP Update Jan for Feb18v2 Page 11 of 15

3. Schemes – Delivered and being monitored


Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect

Ratin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

CIP004-17 Operations Transactional Operational Budget

Reserves

LW 150,000 150,000 Rec A G G G A A

Removing an uncommitted reserves budget. The scheme has delivered and will be monitored for cost pressures. Under review for closure.

CIP003-17 Operations Transformational

Dudley Primary Care and IAPT

Decommissioning

LW 200,000 200,000 Rec R R G G R R

Reduce expenditure on service by £200k in line with CCG reductions. The reduction has been transacted, and is being monitored. Risks remain red, but are being managed in SDP026-16 Improving Access to IAPT. The scheme had been reviewed for closure and was presented to MExT, who have kept the scheme open and under monitoring, due to these red risks.


4. Schemes – Delivered and Closed


Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect

Ratin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

CIP014-17 Corporate Transactional TCT Back Office

AW/RD 50,000 100,000 Rec G G G G G G

This project will reduce the requirement of redeployment/redundancy when the TCT Trusts merge in coming months/years. This will contribute to current and future cost saving schemes. Savings have been identified from vacancies and meet the PYE. £54k has been transacted recurrently, which will deliver £115k (over delivering on its FYE target). The scheme has been reviewed and closed.

CIP019-17 Operations Transformational Walsall Carers Service

LW 56,250 75,000 Rec A G G G A G

Decommissioning of the carers service by the CCG will deliver savings. Savings have been realised, scheme delivered and closed.

CIP011-17 Trust Wide Transactional Inflation Top-slice

RD 125,000 125,000 Rec G G G G G G

Top-slice of inflation dependent on budget setting. The scheme has delivered and been closed

CIP015-17 Trust Wide Transactional Non-recurrent Savings

RD 500,000 500,000 Non Rec A G G G G A

A non-recurring contribution to the recurring shortfall of the 2016/17 QIPP. This relates to end of year provisions which may not be required in 2017/18, and can therefore be used to offset slippage on the QIPP. The scheme has delivered and been closed.

CIP017-17 Trust Wide Transactional Budgetary Reserves RD 500,000 500,000 Rec A G G G A G


4. Schemes – Delivered and Closed


Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect

Ratin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

Savings from budgetary reserves. The scheme has delivered and has been closed.

Key: Scheme value in year non-recurrent

5. Schemes – Closed without delivery


Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect

Ratin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

CIP007-17 Operations Transformational Establishment Review

RM 125,000 250,000 Rec R R R R - -

The small amount of recurrent savings identified has been transferred to new scheme CIP021-17. As the original plan did not deliver any further savings, and this scheme has been closed down.

CIP013-17 Trust Wide Transformational Maximising

Apprenticeship Levy AW 60,000 240,000 Rec R R R R A G


5. Schemes – Closed without delivery


Finance

Recu

rren

t/

Non

Rec

urre


Scheme value in

year (£)

Planned FYE value

(£)

Ove

rall

Proj

ect

Ratin

g

Plan

Deliv

ery

CY

Fina

nce

Deliv

ery

FY

Fina

nce

Risk

s & Is

sues

QIA

This scheme looked at opportunities to introduce apprenticeships with scope to generate non recurrent savings. This scheme has not delivered and has been closed.

Scheme CIP022-17 has been opened to deliver the shortfall.



Agenda Item number: 8.1.3a

Enclosure: 14

Report Title:

Workforce Committee Chair’s Report

Committee:

Workforce Committee

Author:

Harry Turner – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Introduction The Workforce Committee met on the 23rd January 2018 and considered and discussed key topics around the Trust’s Workforce. The Workforce Committee agenda is categorised under 4 main areas, i.e.

- Workforce Performance - Staff Wellbeing - Organisational Development - Workforce Compliance

Summary of key points, issues and risks WORKFORCE PERFORMANCE Workforce Performance Report Month 9 Key messages from the Workforce Performance Month 9 report were:

• Vacancies – There are currently 101 Full Time Equivalent contracted vacancies across the Trust meaning the vacancy rate has increased slightly to 9.2% in Month 9 from 8.9% in Month 8.

• Turnover – The 12 Month Turnover rate has increased from 12.81% to 13.54%. Turnover amongst Corporate Services is of concern as rates are increasing and anecdotally this is due to the pressures of TCT.

• Sickness Absence – The rolling 12 month sickness rate has increased to 4.13% in Month 9 from 3.98% in Month 8, this is expected given we are in the winter period.

• Appraisal – Compliance has increased to 85.1% in Month 9 from 83.9% in Month 8, which is in line with the Trust target of 85%.

• Mandatory Training - Mandatory Training compliance has increased to 90.2% in Month 9 from 89.4% in Month 8 and is in line with the target of 90%.

Enc 17 Enc 14 WFC Chairs Report M9 17 Page 1 of 5

• Essential Skills Training compliance has increased to 73.5% in Month 9 from 72.2%, this is below target but has been on an upwards trajectory from the last 12 months.

Essential Skills Training Plan Whilst compliance with Essential Training is increasing, it is not at the desired rate. A number of actions are being taken forward to increase compliance which includes:

• A focus on levels of DNA training. • Stagger targets for essential training compliance i.e. 80% target by year end and 90%

by end of Quarter1 2018/19. • Commissioned additional essential training places January - March 2018. • Mandatory training as sole terminology to describe mandatory and essential areas of

training form 1st April 2018. • Identify clinical champions for specific training to help increase compliance

STAFF WELLBEING Leavers Analysis Quarter 2 - 3 2017/18 analysis of leavers information was presented. Data collected suggests that the main reasons for employees leaving the Trust voluntarily relate to Retirement and the desire to further their careers and prospects. There is evidence of a high proportion of leavers leaving the Trust within the first 5 years. In particular the data suggests that Band 5 Inpatient nurses are most likely to leave within the first 5 years of their employment with the Trust. There has been an increase in the number of staff leaving the Trust from Corporate services and some free text comments cite TCT as a contributory factor. There is almost no mention of bullying and harassment being a reason for leaving the Trust within the period looked at. Overall the Trust was rated well by leavers. The Acting Director of People and Acting Director of Nursing are looking to develop a recruitment and retention plan for nursing. Flu Campaign The committee were informed that the Trust’s Flu vaccination rate as of 23rd January 2018 is 67% for frontline/clinical workers and is the highest vaccination arte the Trust has achieved thus far. The CQUIN target is 70% to be achieved by the end of February 2018. ORGANISATIONAL DEVELOPMENT Workforce Planning Following on from the submission to Health Education England (HEE) in December 2017 for the STP’s Black Country Workforce Plan the Committee received a report proposing a review of the Trust’s current workforce plan and to refresh the plan for 2018/19. The Trust will also need to work in partnership with Black Country Partnership FT NHS Trust to develop a joint Mental Health workforce plan for the Black Country STP to be submitted in March 2018. The Trust will also be working with MERIT partners on a MERIT Wide mental health workforce plan. These will be presented to the Board in March/April 2018.


Appraisal Review An update was provided regarding the work which is being undertaken through TCT on developing the appraisal process. The aim of reviewing the approach to appraisal across each of the Trusts is: • To support development of a consistent policy and process for the unified organisation. • To facilitate effective management of performance across a range of staff groups on an

annual, mid-year and regular 1-2-1 basis. • To support the aims and objectives of the unified organisation. • To support development of a desired culture within the TCT organisation. A progress update will be providing to the Committee. HEE Draft Workforce Strategy For the first time a Workforce Strategy for Health has been developed by Health Education England. The strategy focusses on 6 key areas i.e.

1. Securing the supply of staff 2. Ensuring a flexible workforce through education and training 3. Proving broad pathways for careers 4. Widening participation in NHS jobs 5. Ensuring the NHS and other employers are inclusive and model employers 6. Ensuring the service, financial and workforce planning are intertwined

The Committee will consider a Trust response to the strategy which will be fed back to HEE which is due by 23rd March 2018. WORKFORCE COMPLIANCE Workforce Risk Register The Committee received the workforce risk register and the Committee was assured that the risks are being appropriately managed. The Risk Register has been reviewed and updated as below: Risk No

Risk Update RAG Rating

456 Failure of the Trust to achieve its essential training may result in staff not being appropriately skilled to undertake their role and Impact upon the Trust meeting compliance with CQC standards and impact upon the quality of patient care

Controls to include: • combining Mandatory training and

essential training terminology • Additional training commissioned • Staggered ET target to be achieved by

Q1 2018

Remains Red

466 Transition through TCT results in staff from Corporate services feeling disengaged or fearful around their jobs resulting in decreased engagement levels, increased sickness rates and increased turnover

Controls to include TCT Capacity plan developed

Remains Red

359 Award of Dudley MCP to an external provider may mean that "community" services and staff transfer to a new provider.

Risk score to increase given DGH is likely to be split and become the MCP and that TUPE is likely to apply

Amber


370 Trust not compliant with IR35 regulations by 6th April 2017

Risk to be removed as controls in place To remove

377 Trust not compliant with Right to Work Checks for existing staff. ESR is missing some key information around Nationality and Residence Status for approximately 70 Staff

Following deep dive of ESR assurance could not be provided that ESR holds the necessary information required to satisfy the Home Office. A plan is being developed to rectify the missing information.

To increase to Red

379 Shortage of National Junior psychiatric trainees in future national rotations may impact on patient care due to reduced workforce capacity and in addition to this there may be on going challenges going forward nationally.

Currently managed well and not an issue but remains as a risk for August 2018 rotation

Downgrade to green

BAF Review The Board Assurance Framework was reviewed and it was agreed that the risks around clinical recruitment/vacancies and corporate would be differentiated given the different issues related to clinical recruitment and impact of TCT on corporate staff/vacancies. Given the increasing anecdotal evidence of the reasons for and real examples of vacancies, the Committee were of the opinion that the risk score should be escalated to a 4 by 4 (16) Red risk Safe Staffing Levels The Committee received the Month 9 Safe Staffing report. No concerns have been raised regarding fill rates.

• Across the inpatient areas the overall fill rates are 101.51%, with 97.77% for registered staff and 103.82% for care staff. This indicates the Trust is meeting the optimum level of fill rates.

• Typically where our care staff rates exceed 100%, this is due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity.

• There are two wards to note as exceptions, whereby staff fill in part is within the lower category (Kinver and Malvern). An impact assessment has been completed that provides assurance safe staffing levels have not been compromised.

• Where staff have concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In December there are two incidents reported related to safer staffing in inpatient services.

• The Trust has in place a locally agreed standard of the minimum of 2 qualified members of staff per shift. Due to inpatient vacancies the Director of Nursing and has sought further assurance that when the ward plans to drop below this standard, mitigations are in place to maintain patient safety. Assurance has been provided that full consideration is given to skill mix when using temporary staff especially on night shifts when this has resulted in with one qualified member of staff being on duty with back up from the night coordinator as a qualified senior nurse and experienced HCAs. Assurance has been provided form Ward Managers that patient safety has not been compromised in changes in skill mix.

Interfaces with other Committees


The business that was discussed by the committee interfaces with the following Committees / Groups:

• MEXT • Finance & Performance Committee • Quality & Safety Committee • CARM • CQRM

Recommendation and requests for direction The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Workforce Committee


WORKFORCE COMMITTEE MEETING

Minutes of a meeting Held on Tuesday 19th December 2017

Board Room, Canalside House, Walsall

START TIME 13:30 HOURS Present: Harry Turner Associate Non-Executive Director (Chair) Mark Axcell Chief Executive Officer Ashi Williams Acting Director of People Rosie Musson Acting Director of Nursing (part, attended from item 107.1) In Attendance: Mark Banks Deputy Director of Finance Becky Temple Purcell Senior Workforce Development Manager Michelle Carr Communications and Engagement Manager Daniel Peniket ESR Systems Manager Dr Kate Gingell Joint Medical Director Nick Stephens Head of Community Services Hassan Omar Head of Social Care Jacky O’Sullivan Clinical Development Director/Acting Associate Director of

Operations Debbie Cooper Head of Service - Inpatients and Home Treatment Services (entered

after item 104.1.2) Michael Hirons Staff Engagement Lead/FSUP Guardian Helen King Note Taker Apologies: Lesley Writtle Acting Director of Operations Anne Marie Carey Head of Urgent Care and Access Services Paul Singh Equality and Diversity Manager Hannah White Senior HR Business Partner Peter Hayward Consultant Occupational Therapist Paul Lewis Grundy Company Secretary Rupert Davies Interim Director of Finance Dr Mark Weaver Joint Medical Director ACTION 101. Welcome and Apologies for Absence

101.1 Apologies were noted as above.


Agenda Item number: 8.1.3b

Enclosure: 15

Enc 15 Final WFC Minutes 19.12.27 v1.0 Page 1 of 7

102. Declarations of Interest

102.1 No declarations of interest noted.

103. Minutes of Previous Meeting held on 27th November 2017

103.1 The minutes of the previous meeting held on 27th November 2017 were agreed as an accurate record.

104. Matters Arising

104.1.1 104.1.2 104.1.3 104.1.4 104.1.5 104.1.6

Action point 33.1; a handover document had been prepared but this had been put on hold due to the delay with the TCT integration. Action closed. Action 76.1; this had been looked in to, with the average time being 6.9 days. It was usually another 7 days before the post was advertised. An update was being made to the system so that the duration to advert could be monitored. Action complete and closed. Mrs Williams confirmed that the recruitment process could start for a post prior to an employee officially handing their notice in. She encouraged all managers to begin the recruitment process as soon as possible. In addition to this a message was due to go out in Wednesday Wire to stress to managers that they did not need to wait until an employee’s last working day to complete a termination form, as this had been a problem recently. Mrs Cooper entered the meeting. Action 82.2; on Agenda. Action complete and closed. Action 89.1; BAF narrative had been completed. HCA bank rate work was on hold due to TCT delay. Action complete and closed. Action 98.1; Mr Banks had attended the STP Directors of Finance Meeting on 15th December 2017 and highlighted the occupational health tender. The STP had advised that they wanted to keep an eye on opportunities and tenders within the region. The view had been that it would be beneficial to be cited on these matters in the future so as they could ensure STP wide synergies could be gathered, and funds released. Action complete and closed. Action 91.1; essential training had been discussed at Executive Communications Meeting on Monday 18th December 2017. The item had been deferred to January’s Committee meeting to ensure that a full report could be submitted. Mr Axcell advised that as of the 1st April 2018 the distinction between essential and mandatory training would disappear; all essential training would become mandatory. Executives


104.1.7

had agreed trajectories to ensure compliance was met, and Mrs Temple-Purcell was looking at the capacity needed to achieve this. Action to remain open; update due in January 2018. Action 90.1; Mr Banks advised that work was being undertaken as requested by the Committee regarding IR35; the situation looked positive. A report would be provided to the January Committee as planned. Action to remain open; update due in January 2018.

105. Workforce Report Month 8

105.1 The Committee reviewed the Workforce Performance Report at Month 8. The following points were raised and noted:

- There were currently 97 FTE contracted vacancies across the Trust; the vacancy rate had remained at 8.9%.

- Turnover had increased to 12.81%. - Turnover within corporate services was increasing. - Sickness had seen a slight increase to 3.98%. It was possible this

was due to the early Payroll cut off in December, therefore the sickness information would be re-run next month to confirm. The sickness levels were not considered a concern as a season increase was usual. Mr Axcell requested that this information be circulated ahead of the next Committee meeting so it could be ascertained whether it was seasonal or if there were any issues. Action: Mrs Williams to circulate the refreshed month 8 sickness information, by department, ahead of the Committee meeting in January 2018.

- Appraisal compliance had reduced to 83.9%, which was below the Trust target (of 85%).

- Mandatory training compliance was noted as 89.4%, which was below the target of 90% agreed at MExT. It was thought that since the report was run that compliance levels had increased to approximately 90%.

- Essential skills training compliance was still below target, at 72.2%.

The Chair expressed his disappointment regarding the appraisal compliance. Mrs O’Sullivan explained that she had flagged this up with the relevant service leads and areas concerned. Mrs Cooper advised that she was looking in to her areas and would ensure an up to date position in time for the January 2018 report. Mrs Williams advised that there was still an issue with managers not informing HR that appraisals had taken place. 93% of staff had reported, within the staff survey, that they had received an appraisal within the last 12 months. It was thought the issue could therefore be regarding data quality. Mrs Temple-Purcell explained that longer terms plans were being addressed with regards to the appraisal process along with TCT partners. The appraisal process was being reviewed; focus groups were planned to ascertain what the process should look like.

Mrs Williams


Action: Mrs Temple-Purcell to establish whether any work had been undertaken regarding appraisals within the MERIT vanguard, and take up any opportunities there. It was highlighted that due to the impending TCT integration the Trust had not looked at the outcomes from appraisals, e.g. regarding staff performance, training needs analysis, talent management etc. Mr Peniket advised, for the same reason, he had paused his work of transferring the appraisal process online (on to ESR). This would now be progressed over Christmas and the New Year period. The Chair stressed the need to modernise the process with regards to paperwork and ensure the approach was tailored to different employees. The Trust understood where the gaps were and was in the process of closing them. Mandatory training would be re-focused upon to ensure compliance as all courses were available via e-learning, and via mobile phone, and could be undertaken from home if needed. This information would be communicated to staff again shortly. Dr Gingell highlighted the e-learning methods, for example undertaking it on a mobile phone, and having certain training modules without an assessment at the end; deep learning was questionable, and it needed to be ensured that the principles of learning are followed. However, it was also noted that it was about increasing accessibility and giving employees the choice of what suited their needs. The Chair advised that whatever method was put in place, it needed to be sustainable, and data quality issues needed to be resolved. The Committee received the report for assurance.

Mrs Temple-Purcell

106. Staff Survey

106.1 Mr Hirons updated the Committee on the preliminary results of the staff survey. It was highlighted that the results were embargoed until the end of January/early February 2018, and therefore were only for internal communication at present. The full results would be released at the end of January 2018, and shortly after would be accessible in the public domain via the internet. The following was noted:

- There had been a return rate of 52%. - The overall engagement score and benchmarking information

would not be available until February 2018. The Trust could however benchmark against its TCT partners, who had rated lower than the Trust overall.

- Results were RAG rated against 2014, 2015, and 2016 results, and by sector. Scores RAG rated as green had slightly improved from 2016, with the figure being 74.71%.

The improvements were noted against last year; the Committee were


pleased with the positive results which had been obtained within the current challenging environment. It would be ensured that the Trust protected what it was doing well and carried these in to the TCT partnership, and worked on those areas requiring improvement. Mr Axcell and the Chair commended everyone’s hard work. The positive results were testimony to MExT members. The Trust had been ahead of the field last year, and some of the figures had improved further with was good. Trust Board would be informed of the preliminary results.

107.

Workforce Risk Register

107.1 The Chair advised that the Risk Register needed to be reflective of the Trust in its current position as a standalone organisation; many of the risks over the past several months had been populated or mitigated with TCT matters. Mrs Williams took the Committee through the Risk Register, which had been reviewed since the last meeting. The following was noted: Risk 456 – Essential Training The risk remained red. Focus would remain on this area. The Chair queried whether the residual score was green taking in to account the actions noted. Action: Mrs Williams to update the narrative for Risk 456 ‘further actions’ tab with the work that had been completed at the Executive Communications Meeting. Risk 466 – Corporate Staffing This risk had been discussed at the Committee in November 2017 and added as a new risk as requested. Action: Mrs Williams to ensure the turnover rates for corporate services staff were circulated to the Committee. Resources for corporate services were being looked at, what vacancies there were, where roles were being covered, what capacity there was, and any risks and gaps which had arisen. Recruitment would be undertaken as necessary. It also needed to be considered whether greater certainty could be provided to staff regarding job security and travel arrangements. By the 8th January 2018 plans would be in place for Corporate Services. Ms Musson entered the meeting. Risk 368 – Transition through TCT - effect on staff This risk was related to Risk 466, but concerned all staff. The risk was amber as there was still a lack of certainty about the TCT transaction date. The Trust continued to work collaboratively with TCT partners. The Trust needed to ensure it focused internally now, and ensure actions were in place to protect the RAG position. Risk 359 – MCP award to external provider This risk was dated now as it was known that the Trust were part of the

Mrs Williams Mrs Williams


favoured consortium. Action: Mrs Williams to review and update risk 359 with the current MCP position. The Committee noted the actions taken to date on the risks discussed and asked Mrs Williams to make the appropriate amendments. The risks included within the report were approved. It was agreed that red risks 456 (essential training), and 466 (TCT transition effect on corporate staffing), would be reported to Trust Board.

Mrs Williams

108. Safer Staffing

108.1 Mrs Musson talked the Committee through the Safer Staffing Monthly Exception Report, which presented data for November 2017 and a monthly trend analysis for a 12 month period. Headlines were as follows:

- The overall fill rate was steady, at 101.11%. There were a couple of exceptions, which were Malvern Ward and Kinver Ward, where the registered nurses on night were in the low range. This had been managed in a safe way. There were vacancies in these areas, and staff sickness on Malvern Ward. Recruitment was on-going.

- Panned and actual demand was shown under item 4. The Trust was matching demand; however there was still a shortfall on night shifts due to vacancies and sickness. However staffing was above on day shifts due to such things as level of observations. This was being discussed with commissioners.

- The picture remained consistent regarding registered nurse hours versus temporary fill.

- Agency staff usage had reduced which was positive. Agency usage was higher on Langdale Ward (6.2%) due to long term sickness.

- Vacancies were fairly consistent across all wards, and there were also staff on secondments which affected the staffing.

- Care staff versus temporary fill showed agency usage at 3.1% for November 2017 which was very positive.

- The Graph on page 11 was identical to that on page 9. It would be ensured that errors like this were not made in future reports.

- Night time compliance, with a minimum of 2 staff members per shift, was looking more positive. Once there was a full establishment of staff there should be no issues at all. Mrs Cooper advised that there were currently about 2 vacancies per ward, and on-going recruitment resulted in about 2 or 3 nurses being appointed each month. The Chair proposed a specific recruitment campaign was undertaken, including the positive staff survey results, in order to drive more rapid recruitment.

- Skill mix would be looked at, along with the nurse practitioner role, within the next establishment review.

- Mr Williams advised that NHS employers were leading a programme regarding retention which would help in the long term.

It was clarified for the Chair that ward demand was planned 6 weeks


ahead of time, with the demand being flexed the week before depending upon need. There was a defined process to manage the movement in demand. If the actual was significantly lower than the demand it would flag up. The Hurst Tool was being piloted within mental health nationally at present, but the overriding factor was clinical judgement, with the Hurst Tool to assist. The Chair was pleased with the progress in this area, and the positive work being undertaken to close the current gaps on night shifts. The Committee received the report for assurance.

109. Any Other Business 109.1 STP Workforce Plan

Mrs Williams explained that information had been sent out via Health Education England to STPs regarding mental health workforce plans. An integrated Black Country wide response was returned. This had been circulated to the Committee, and the Trust’s internal leads. It had also been submitted to a TCT/STP meeting on 18th December 2017. In terms of long term workforce planning, there would need to be a Black Country wide STP workforce plan. Action: Black Country wide STP workforce plan to be discussed at January’s Committee meeting. Flu Jab The Committee were advised that 67% of front line clinical staff had received he flu jab, this needed to increase to 70% by the end of February 2018 if the CQUIN was to be achieved. National Workforce Strategy This had been written. Action: Mrs Williams to update the Committee on the National Workforce Strategy in January 2018.

Mrs Williams Mrs Williams

110. Date and Time of Next Meeting 110.1 Tuesday 23rd January 2018

Conference Room 1, Trafalgar House, King Street, Dudley 13.30 – 15:30 hours




Workforce Report Month 9 – 2017/18

Workforce Report - Contents Page

• Key Messages • Workforce Dashboard • Recruitment • Turnover • Sickness • Appraisal • Mandatory Training

3 4 5 6

7-8 9

10

2

Vacancies – There are currently 101 Full Time Equivalent contracted vacancies across the Trust meaning the vacancy rate has increased slightly to 9.2% in Month 9 from 8.9% in Month 8. Turnover – The 12 Month Turnover rate has increased from 12.81% to 13.54%. The percentage turnover, excluding junior medical staff is average compared with other mental health organisations in the NHS. Sickness Absence – The rolling 12 month sickness rate has increased to 4.13% in Month 9 from 3.98% in Month 8, this is within the Trusts target and the thirteenth consecutive month of being so. In month sickness has increased from 4.98% in Month 8 to 5.29% in Month 9. Appraisal – Compliance has increased to 85.1% in Month 9 from 83.9% in Month 8, which is in line with the Trust target of 85%. There are 137 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 178 reported in January 2017. Mandatory Training - Mandatory Training compliance has increased to 90.2% in Month 9 from 89.4% in Month 8 and is in line with the target of 90% agreed at MEXT for all mandatory training. Essential Skills Training compliance has increased to 73.5% in Month 9 from 72.2%, this is below target but has been on an upwards trajectory from the last 12 months.

3

445 Dudley and Walsall Mental Health Partnership NHS Trust

Staff in PostTarget Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Headcount 1074 1088 1089 1088 1092 1090 1098 1097 1110 1106 1109 1105Funded Establishment 1138.3 1150.2 1148.2 1148.2 1151.2 1147.7 1102.5 1105.4 1106.5 1102.5 1102.5 1102.5Staff in Post FTE (Contracted) 978.8 991.8 992.2 992.7 996.0 994.5 1003.7 1004.7 1011.9 1004.2 1004.9 1001.2WTE Variance 159.5 158.4 156.0 155.4 155.2 153.1 98.8 100.6 94.6 98.3 97.6 101.3Vacancy % 10.0% 14.0% 13.8% 13.6% 13.5% 13.5% 13.3% 9.0% 9.1% 8.6% 8.9% 8.9% 9.2%Clinical Vacancy % 10.0% 11.6% 12.1% 11.4% 10.1% 10.2% 10.4%Turnover % (12 Months) 8-14% 10.72% 10.33% 10.53% 11.56% 11.40% 11.18% 11.21% 11.97% 12.46% 12.68% 12.81% 13.54%

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

Funded £ £4.34m £4.39m £4.49m £4.16m £4.28m £4.35m £4.14m £4.29m £4.25m £4.25m £4.32m £4.34mSubstantive Spend £ £3.63m £3.70m £3.60m £3.73m £3.68m £3.75m £3.68m £3.39m £3.72m £3.72m £3.79m £3.52mTemp Spend £ £0.54m £0.58m £0.58m £0.38m £0.49m £0.54m £0.50m £0.79m £0.49m £0.49m £0.50m £0.86mTotal Pay Spend £ £4.16m £4.28m £4.18m £4.11m £4.17m £4.29m £4.19m £4.18m £4.22m £4.22m £4.29m £4.38mVaraince - Budget to Actual £ £171K £111K £307K £52K £116K £55K -£45K £113K £37K £37K £37K -£45K

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

Sickness % (Month) 4.68% 4.89% 4.57% 3.34% 3.59% 3.40% 4.01% 4.02% 3.35% 3.96% 3.91% 4.98% 5.29%Sickness Days Lost FTE (Month) 1,476 1,263 1,030 1,069 1,049 1,196 1,244 1,030 1,192 1,219 1,501 1,644No of Sickness Episodes (Month) 223 166 144 128 128 155 153 139 165 176 204 222Cost of Sickness (Month) £114K £102K £90K £90K £81K £100K £111K £76K £89K £88K £113K £124KMaternity % (Month) 2.12% 2.19% 2.23% 2.05% 2.23% 2.36% 2.42% 2.35% 2.22% 2.06% 1.68% 1.75%Sickness % (12 Months) 4.68% 4.42% 4.39% 4.31% 4.24% 4.14% 4.11% 4.05% 3.93% 3.88% 3.88% 3.98% 4.13%Long Term Sickness % (12 Months) 64.0% 63.2% 62.9% 62.6% 63.5% 61.6% 62.5% 60.0% 59.6% 59.3% 60.9% 63.0%Cost of Sickness (12 Months) £1,292K £1,271K £1,260K £1,249K £1,208K £1,198K £1,195K £1,140K £1,110K £1,105K £1,136K £1,179K

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

Appriasals Completed 687 744 761 740 722 729 757 801 794 767 762 783Appraisals Outstanding 178 121 114 126 147 150 136 110 113 135 146 137Appraisals Required 865 865 875 866 869 879 893 911 907 902 908 920Appraisal % 85% 79.4% 86.0% 87.0% 85.5% 83.1% 82.9% 84.8% 87.9% 87.5% 85.0% 83.9% 85.1%Mandatory Training % 90% 88.9% 88.9% 89.8% 88.0% 88.6% 88.3% 90.6% 92.0% 90.5% 90.1% 89.4% 90.2%Essential Skil ls Training % 90% 58.3% 66.1% 66.9% 68.3% 70.2% 71.8% 72.1% 73.7% 74.5% 71.3% 72.2% 73.5%Number of Training DNAs 52 119 99 70 75 117 111 109 82Training DNA Rate % 14.1% 22.0% 19.4% 14.5% 19.4% 21.3% 17.3% 17.2% 26.5%

Dec-17

4

The table above shows the number of adverts published on NHS jobs in November and the associated Whole Time Equivalent (WTE) by Staff Group. 10 of the WTE advertised for Nursing & Midwifery Registered were for Band 5 Ward Staff Nurses, and therefore more/less than 10 WTE could be recruited to the position due to it being a rolling recruitment advert.

Staff GroupNo of

advertsWTE

AdvertisedAdvert views Applications

Application to advert view rate

Applications per WTE

Avg no of days

advertisedAdditional Clinical Services 2 2.0 86 4 0.0 2.0 13.5Additional Professional Scientific & Technical 0 0.0 0 0 - - -Administrative & Clerical 7 18.8 4014 123 3.1% 6.5 8.0Allied Health Professionals 2 2.0 1457 3 0.2% 1.5 17.0Estates & Ancillary 0 0.0 0 0 - - -Medical & Dental 0 0.0 0 0 - - -Nursing & Midwifery Registered 7 19.0 5583 42 0.8% 2.2 21.6Total 18 41.8 11140 172 1.5% 4.1 14.9

5

12 Month Turnover has increased to 13.54% in Month 9. This is the fourth consecutive month showing an increase, the impact of TCT may be having an impact. This is still within the Trusts targeted range and could be considered a good indicator that the Trust in general retains its staff.

10.7% 10.3% 10.5%

11.6% 11.4% 11.2% 11.2%12.0%

12.5% 12.7% 12.8%13.5%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

13.0%

14.0%

15.0%


DWMH Turnover % by Month

Target Range Turnover %

ServiceStarters FTE

(Month)Leavers FTE

(Month)Turnover %(12 Months)

445 CAF Corporate Affairs Level 3 0.0 0.0 27.8%445 CDP Corporate Development and People Level 3 0.0 0.0 0.0%445 CDS Clinical Development Level 3 0.0 2.4 24.5%445 CHX Chief Executive Level 3 0.0 0.0 19.5%445 FIN Finance Level 3 0.0 0.0 36.4%445 HR Human Resources Level 3 0.0 0.0 19.8%445 OPS Operations Level 3 0.4 2.4 15.0%445 MED Medical Level 3 3.0 2.2 19.1%445 AOMGT Acute & Older Adults Management Level 3 0.0 0.0 13.7%445 COM Community Services Level 3 0.4 0.0 9.5%445 EIN Early Intervention Level 3 3.0 1.0 12.0%445 INP Inpatient Services Level 3 0.0 3.0 9.5%445 UCA Urgent Care & Access Level 3 0.0 3.0 15.1%445 Dudley and Walsall Mental Health Partnership NHS Trust 6.8 14.0 13.5%

6

The rolling 12 month sickness rate increased in Month 9 to 4.13% from 3.98% in Month 8. This within the trusts target 4.68%. In month sickness has increased from 4.98% in Month 8 to 5.29% in Month 9.

445 UCA Urgent Care & Access Level 3 4.06% 4.76% 4.59%445 Dudley and Walsall Mental Health Partnership NHS Trust 4.98% 5.29% 4.13%

7.41% 6.23% 5.41%445 INP Inpatient Services Level 3

445 AOMGT Acute & Older Adults Management Level 3 0.38% 1.66% 3.27%445 COM Community Services Level 3 7.57% 9.39% 4.57%445 EIN Early Intervention Level 3 4.43% 4.22% 2.88%

445 OPS Operations Level 3 2.86% 4.81% 4.76%445 MED Medical Level 3 0.67% 1.86% 2.76%

445 HR Human Resources Level 3 0.10% 0.36% 0.72%445 FIN Finance Level 3 3.88% 1.86% 1.96%

0.33%445 CDS Clinical Development Level 3 5.72% 5.20% 5.78%

445 CAF Corporate Affairs Level 3 2.13% 5.02%

Service Nov-17 Dec-17Sickness %

(12 Months)1.52%

445 CDP Corporate Development and People Level 3 0.56% 0.00% 0.37%

445 CHX Chief Executive Level 3 0.00% 0.00%

4.80%4.59%

3.33%

3.59%3.40%

4.01% 4.02%

3.35%

3.96% 3.91%

4.98%

5.29%

3.00%

3.50%

4.00%

4.50%

5.00%

5.50%


Sickness Absence % v Trust Target

Target Sickness % Sickness % 12mth

7

Long term sickness accounts for 63% of sickness for the rolling 12 month period to Dec-17. The top 3 reasons for sickness based on Full Time Equivalent days lost for Month 9 were: 1. Anxiety/Stress – 515 2. Other musculoskeletal

problems – 206 3. Cough, Cold, Flu - 133

1.4% 1.4% 1.0%2.1%

1.1% 1.5% 1.5%

2.09%3.16%

1.87%

3.28%

1.68%

3.05% 2.60%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

445 CorporateLevel 2

445 COMCommunity

Services Level 3

445 EIN EarlyIntervention Level

3

445 INP InpatientServices Level 3

445 MED MedicalLevel 3

445 UCA UrgentCare & Access

Level 3

445 Dudley andWalsall Mental

Health PartnershipNHS Trust

Short Term/Long Term Sickness % (Rolling 12 Months)

ST% LT%

Add ProfScientific and

Technic

AdditionalClinicalServices

Administrativeand Clerical

Allied HealthProfessionals

Estates andAncillary

Medical andDental

Nursing andMidwiferyRegistered

DWMH

Nov-17 3.82% 9.08% 3.47% 5.96% 0.54% 0.62% 5.28% 4.98%Dec-17 0.64% 9.71% 4.35% 12.22% 2.67% 1.74% 4.96% 5.29%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%Sickness Absence Comparison by Staff Group

8

Appraisal compliance is tracking at 85.1% at the end of Dec-17. This is above the Trust target There are 137 employees in the Trust that haven't had an appraisal recorded on ESR in the last 12 months.

79.4%

86.0% 87.0% 85.5% 83.5% 82.9% 84.8%87.9% 87.5%

85.0% 83.9% 85.1%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal % v Trust Target

Target Appraisal %

ServiceAppraisals Required

445 CAF Corporate Affairs Level 3 10445 CDP Corporate Development and People Level 3 4445 CDS Clinical Development Level 3 17445 CHX Chief Executive Level 3 5445 FIN Finance Level 3 28445 HR Human Resources Level 3 15445 OPS Operations Level 3 88445 MED Medical Level 3 89445 AOMGT Acute & Older Adults Management Level 3 25445 COM Community Services Level 3 167445 EIN Early Intervention Level 3 122445 INP Inpatient Services Level 3 246445 UCA Urgent Care & Access Level 3 104445 Dudley and Walsall Mental Health Partnership NHS Trust 920 83.9% 85.1%

89.9% 90.2%79.6% 85.4%

88.2% 94.1%100.0% 100.0%

83.3% 80.7%

85.7%93.3%

82.1%93.3%

100.0% 100.0%

Nov-17 Dec-17

90.0% 100.0%

+/-

76.1%

82.8% 79.8%

82.0%88.5% 88.0%87.4% 85.0%

9

445 Dudley and Walsall Mental Health Partnership NHS Trust

Training Compliance

Competence Target Completed Required % +/- Completed Required % +/-Mandatory Training 90% 7615 8516 89.4% 7523 8344 90.2%

kMandatory Training

Competence Target Completed Required % +/- Completed Required % +/-Equality, Diversity and Human Rights 90% 968 1040 93.1% 953 1019 93.5%Fire Safety 90% 930 1039 89.5% 912 1019 89.5%Health and Safety 90% 979 1039 94.2% 977 1019 95.9%Infection Control (Clinical) 90% 622 739 84.2% 613 724 84.7%Infection Control (Non Clinical) 90% 283 301 94.0% 277 296 93.6%Information Governance 95% 915 1039 88.1% 900 1019 88.3%Moving and Handling (Foundation) 90% 938 1039 90.3% 934 1019 91.7%Moving and Handling (Patient Handling) 90% 131 248 52.8% 158 239 66.1%Safeguarding Adults Level 1 90% 258 270 95.6% 255 265 96.2%Safeguarding Adults Level 2 90% 685 746 91.8% 668 730 91.5%Safeguarding Children Level 1 90% 251 269 93.3% 247 264 93.6%Safeguarding Children Level 2 90% 655 747 87.7% 629 731 86.0%

Dec-17

Nov-17 Dec-17

Nov-17 Dec-17

10



Enclosure: 17

Report Title: Medical Directors’ Report Accountable Director:

Dr Weaver, Joint Medical Director


Dr Weaver, Joint Medical Director

Purpose of the report: To update the Board on matters pertaining to the joint Medical

Directors’ portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


N/A


services


Leadership culture






Caring There is a potential impact across all the CQC domains Responsive

Effective Well-led Safe

Enc 17 medical director update feb 2018 Page 1 of 4

National and Regulatory guidance The president of the RCPsych Wendy Burn in her January President’s update identified three major areas for focus or ‘ resolutions’ for the new year. These she identified as:

Recruitment Retention The Mental Health Act 1983 Review.

She emphasised that despite some initial progress that the #ChoosePsychiatry campaign remains important with a focus required on ensuring that as many medical students and Foundation doctors experience Psychiatry as early as possible in their career so that they can if possible be influenced to the merits of such a career.

She also emphasised that whilst encouraging attraction to psychiatry was very important it was similarly important to work to make sure that trainees, specialty and associate specialist (SAS) doctors and consultants stay in the profession.

The College is holding a workshop with Health Education England at the end of the month to firm up arrangements for the implementation of the workforce plan that came out last summer.

She states that from speaking with trainees she has received feedback that trainees above all want to be treated with consideration. This she stated means thought being given to where they live when placements are allocated, access to food and rest when on call and ability to take leave for important events when they give reasonable notice. Or in other words, ‘ supported and valued’ as the Psychiatric Trainees’ Committee has set out.

Fortunately she states psychiatric trainees already report being treated better than most specialties via the GMC national training survey, but she emphasises that there is still room for improvement.

The Trusts recruitment and retention of senior medical staff has remained consistently strong including some senior colleagues with valuable experience who have recently chosen to retire and return, and our GMC training survey results which were shown to Board recently were also amongst the strongest. This is encouraging at a time when consultant vacancies are increasing nationally and medical recruitment in psychiatry a consistent challenge.

Mental Health Act review

The College is about to submit evidence for the review of the Mental Health Act 1983. This will feed into the interim report of the review, expected to be published in spring this year, and will be posted shortly on the RCPsych website.

Title Medical Directors’ Report


https://twitter.com/search?f=tweets&vertical=default&q=%23choosepsychiatry&src=tyah

https://www.gmc-uk.org/education/national_trainee_survey.asp

The College will be working closely with the review team and members are invited to continue to feed in opinion in the following manner

directly using the email address [email protected] or via Faculty and Divisional reps on Council.

Topics of interest The GMC's Chief Executive sets out guidance for doctors dealing with the current high-demand across the health service Recently the GMC has issued some guidance for doctors on dealing with the high demands currently placed on many services which borne by all health professionals Charlie Massey, Chief Executive of the General Medical Council, said: ‘I know how hard doctors, and all health care professionals, are working to provide good care in very difficult circumstances this winter. ‘Knowing this season would be challenging the service has clearly worked very hard to prepare but difficult decisions have had to be made including cancelling routine surgery and clearly this will be distressing for many patients. 'If a doctor believes their work environment is unsafe or that they are unable to maintain standards of care we urge them to flag their concerns. We expect those responsible for running the services to listen, consider and act on those concerns. ‘We understand that it’s not always easy to raise an issue but it must be done. Doctors who need advice have a number of options. They may reach out to a senior member of staff, a medical defence body, their royal college or the BMA. We also have a confidential hotline (0161 923 6399) for doctors who feel they can’t report their concern at a local level. Local Matters We continue to have successful recruitment to posts, the most recent in January 2018 being a consultant appointment to the general adult consultant vacancy in the Walsall Locality. Interest in the post was good with a strong field of experienced candidates interviewed who provided positive feedback to as to the Trust’s reputation as a supportive place to work and relating to our continuity models of care in general adult psychiatry. Board members will be aware that we have had ongoing concerns about trainee recruitment in psychiatry which remains a national challenge. However because of persistent work within our postgraduate office we have managed to secure full occupancy of our training posts for the start of February rotation with gaps being filled by fixed term appointments. The Trust has been identified as one of the most consistent in securing medical agency locums within the capped rates. This recognition was received by notification to the medical directorate administrative team with a request to share our experience and effectiveness in applying the capped rates with a trust which has been struggling to stick to the capped rates.


mailto:[email protected]

Further we have gathered evidence to confirm that the rates the trust has been paying for different grades of doctors from consultant, middle grades to juniors are amongst the lowest in the region. This is a reflection of the extremely hard work done by the medical directorate administrative team and possibly suggests that doctors are attracted to work with us for reasons beyond remuneration. Mortality Report The Mortality data for December 2017 and January 2018 will be combined in next month’s report to Board. The governance team has not met this month to review and collate the data for December which will be considered in conjunction with the data for January 2018. Recommendation The Board is asked to receive the Medical Directors’ report for information and assurance. Board action required To receive the report for assurance.




Enclosure: 18

Report Title:

Director of Nursing Report


Rosie Musson – Acting Director of Nursing



Purpose of the report: To update the Board on matters pertaining to the Director of

Operations and Nursing portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A


N/A




x

Leadership culture






Caring The report relates to all domains and supports the Trust in the delivery of the CQC Fundamental Standards of Care

Responsive Effective Well-led Safe

Enc 18 DoNs Board Briefing February 2018Page 1 of 3

Title Director of Nursing Report

DONs update Walsall Safeguarding and looked After Children’s inspection The Trust was informed on Thursday 18th January 2018 that the CQC would be conducting an inspection in Walsall of safeguarding and looked after children service. This has commenced and will involve our staff participating in focus groups and case file tracking in CAMHS and Adult Mental Health. Initial feedback will be on Friday 26th January 2018. Smoke Free The smoke free steering group has now reconvened. The Trust continues to learn lessons from other implementation sites and work in partnership with Black Country Partnership NHS Foundation Trust and partners to ensure a cohesive shared approach. The Board will be updated of the time line for implementation in March 2018. Recruitment and retention of Nurses Recruitment and retention of nurses continues to be a focus both nationally and locally. A targeted piece of work has been undertaken but needs refreshing to ensure we are exploring all opportunities. Representation from all service lines will be requested to ensure we are meeting all needs. Learning through national and regional collaborative will be utilised to maximise opportunities for recruitment and retention. The greatest challenge for the Trust remains Band 5 recruitment in inpatient services. This is subject to ongoing monitoring and linked to safe staffing surveillance. Enabling Black and Minority Ethnic (BME) nurse and midwife progression into senior leadership positions A national report summarising learning from engagement work, which identified what the best performing trusts in the Workforce Race Equality Standard (WRES) were doing has been published to enable Black and Minority Ethnic nurse and midwife progression into senior leadership positions. It includes examples that outline best practice approaches and a number of suggested actions to support improvement. The Director of Nursing is currently reviewing the report to ensure learning is incorporated into developing the nursing workforce. Leading Change, Adding Value; a framework for nursing, midwifery and care staff Leading Change, Adding Value is a co-developed and co-delivered national framework for all nursing, midwifery and care staff in England led by the Chief Nursing Officer As a Trust we continue to empower nurses and clinical teams to use the framework to make improvements, this is demonstrated through the nurse development programmes which encourage nurses to make positive changes in their work environment. Examples of best practice have been submitted to the national programme and the framework will be the focus of the next trust professional nurse forum in February.


Recommendation As a result of the above the Board is asked to receive the update from the Director of Nursing portfolio.



Agenda Item number: 8.4 Enclosure: 19

Report Title:

Enhancing Quality through Safer Staffing Levels Monthly Exception Report




Rosie Musson – Acting Director of Nursing Makhan Singh – Principal Consultant, Informatics and Performance

Purpose of the report: This report provides the Trust Board with:

• A summary report of planned and actual staffing for

December 2017, which has been submitted to NHS Choices as part of a national staffing return and is available on the Trust’s website.

• Exception reporting for variances and any concerns relating to safer staffing.

• Trend analysis monthly average fill rate • Bank and agency actual hours analysis v’s substantive

hours • Number of qualified staff per shift

Action required from the Committee Decision / Approval

Gain assurance

Discussion

Information


Committee: Workforce Committee

Date reviewed: 23 January 2018 Key points or recommendations from Committee:

The Committee commended the report to Board

Is referral to Trust Board required? Yes

If yes, for what purpose? For Assurance Strategic Objective(s) to which this paper relates:



Leadership culture




Enc 19 TB Safer Staffing Levels on Wards - Jan 2018 Page 1 of 15

Quality Impact Assessment Domain Comment Patient Safety

Ensuring safer staffing in inpatient services.

Patient Experience

Clinical Effectiveness / Outcomes

Workforce Experience – Efficiency & Productivity

Efficient use of staffing resource to deliver quality care.

Continuous Improvement in the Quality of Care



Caring

Responsive

Ensuring staffing levels are responsive to meeting patient need

Effective

Well-led

Safe

Ensuring staffing levels are adequate to deliver safe care


Title Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Introduction This report provides the Trust Board with: • A summary report of planned and actual staffing which has been submitted to NHS

Choices as part of a national staffing return and is available on the Trust’s website. • Exception reporting for variances and any concerns relating to safer staffing. • Trend analysis monthly average fill rate. • Bank and agency actual hours’ analysis against substantive hours. • Number of Qualified staff per shift

Summary of key points, issues and risks The Data represents December 2017 and a monthly trend analysis for a 12 month period. Across the inpatient areas the overall fill rates are 101.51%, with 97.77% for registered staff and 103.82% for care staff. This indicates the Trust is meeting the optimum level of fill rates. Typically where our care staff rates exceed 100%, this is due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity. There are two wards to note as exceptions, whereby staff fill in part is within the lower category (Kinver and Malvern). An impact assessment has been completed that provides assurance safe staffing levels have not been compromised. Where staff have concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In December there are two incidents reported related to safer staffing in inpatient services. The Trust has in place a locally agreed standard of the minimum of 2 qualified members of staff per shift. Due to inpatient vacancies the Director of Nursing and has sought further assurance that when the ward plans to drop below this standard, mitigations are in place to maintain patient safety. Assurance has been provided that full consideration is given to skill mix when using temporary staff especially on night shifts when this has resulted in with one qualified member of staff being on duty with back up from the night coordinator as a qualified senior nurse and experienced HCAs. Assurance has been provided form Ward Managers that patient safety has not been compromised in changes in skill mix. Enc 19 TB Safer Staffing Levels on Wards - Jan 2018 Page 3 of 15

Recommendation To note and discuss the monthly data return submitted providing details of planned and actual staffing at ward level. Board action required The Trust Board members are asked to:

• To note and discuss the monthly data return submitted, providing details of planned and actual staffing at ward level. Data represents December 2017 and a 12 month trend analysis.


1. Nursing and healthcare staffing fill rates December 2017 The data submission was made on 12th January 2018 of December data. The following table provides a summary of the planned verses actual staffing levels on the inpatient wards. Ward Return

Planned Actual Planned Actual Planned Actual Planned Actual

Cedars 990.00 960.00 952.50 952.50 494.50 494.50 623.50 623.50 96.97% 100.00% 100.00% 100.00%Linden 937.50 922.50 1432.50 1432.50 645.00 634.25 677.25 655.75 98.40% 100.00% 98.33% 96.83%Ambleside 967.75 967.75 1895.45 1895.50 634.25 625.25 1193.25 1192.25 100.00% 100.00% 98.58% 99.92%Langdale 896.75 877.55 1359.45 1358.40 666.50 659.50 666.50 667.10 97.86% 99.92% 98.95% 100.09%Clent 780.00 780.00 1083.5 1083.5 581.50 581.50 721.75 721.75 100.00% 100.00% 100.00% 100.00%Kinver 908.75 911.25 1203.25 1203.25 666.50 548.25 752.50 887.25 100.28% 100.00% 82.26% 117.91%Wrekin 887.05 893.90 675.10 963.65 354.75 354.75 645.00 965.15 100.77% 142.74% 100.00% 149.64%Holyrood 937.50 922.50 3097.50 3105.00 548.25 548.25 1795.25 1795.25 98.40% 100.24% 100.00% 100.00%Malvern 930.00 930.00 1860.00 1882.25 645.00 559.00 1257.75 1343.75 100.00% 101.20% 86.67% 106.84%Grand Total 8235.30 8165.45 13559.25 13876.55 5236.25 5005.25 8332.75 8851.75 99.15% 102.34% 95.59% 106.23%

5ec-175ay Night 5ay Night

RMN Care Staff RMN Care Staff Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Lowest range – less than 80% Highest range – greater than 150% Low range – greater than 80% but less than 90%

High range – greater than 120% but less than 150% Greater than 90% but less than 120% Comments Across the inpatient areas the overall fill rates are 101.51%, with 97.77% for registered staff and 103.82% for care staff. This demonstrates an optimum range of fill rate for qualified and care staff for the demand (number of staff identified as required by the ward to meet patient acuity).


2. Exception Report on Variance – December 2017 Exceptions Rationale Impact Remedial

Actions Kinver Ward – Bushey Fields Hospital 82.26% Night – Average fill rate – Registered Nursing (Low range)

The deficit accounts for the times this has not been successful due to not having a bank/agency trained available. HCA to backfill was used instead of a planned second trained on the night shift. On each occasion mitigations were put in place to maintain safety.

Safe staffing levels maintained, no reported incidents

Continue recruitment to vacancies. Review on monthly basis.

Malvern Ward – Bushey Fields Hospital 86.67% Night – Average fill rate – Registered Nursing (Low range)

The deficit accounts for the times this has not been successful due to not having a bank/agency trained available. HCA to backfill was used instead of a planned second trained on the night shift. On each occasion mitigations were put in place to maintain safety.

Safe staffing levels maintained, no reported incidents

Continue recruitment to vacancies. Review on monthly basis.

There are two incidents reported relating to safer staffing in December 2017. Incident Number

Date of Incident

Location

Incident Summary (taken from report submitted)

Actions/Outcome / Assurance

59544

25th Dec Kinver Ward

Incident Type: Staffing – Insufficient Levels Incident: RMN for night shift on Kinver Ward reported in sick. Agencies contacted for cover to no avail. Plan made for second RMN (agency) on Malvern to be redeployed, however agency staff did not arrive for shift.

Outcome: Skill mix and staffing levels were considered across the site Action: Due to no availability of a qualified nurse for Kinver, the bleep holder from the late shift remained on site and worked within the ward numbers overnight to facilitate the administration of medication. Assurance: Quality and patient safety was not compromised.

59617 30th Dec Kinver Ward

Incident Type: Staffing – Insufficient Levels

Outcome: Skill mix and staffing levels were considered across the site and the decision made to redeploy staff from another ward


Incident Number

Date of Incident

Location

Incident Summary (taken from report submitted)

Actions/Outcome / Assurance

Incident: RMN for night shift on Kinver reported in sick. Agencies contacted for cover to no avail.

that had 2 RMN’s on shift. Action: RMN redeployed from another ward and back filled with agency HCA. Assurance: No incidents were reported by either ward during the shift

3. Trend Analysis average fill rate The following table shows a monthly trend of the total average fill rates planned verses actual for the Trust. This demonstrates that staffing levels are flexed to meet the increases and decreases in patient acuity, which is currently informed by clinical expertise.


4. Planned and Actual Demand

The Trust inpatient safer staffing demand is based on full bed occupancy and one raised observation level. Where additional raised observations are required, this inevitably results in requirements for extra staff, over and above the established demand. These requirements are usually filled by bank and agency workers. Other common reasons for requiring bank and agency workers are vacancies, high levels of staff sickness, multiple patient reviews and patient escorts off-site.

The below table highlight planned vs actual demand for the Trust in December 2017.

The RMN Day planned demand is in line with the actual demand used by the Trust, and there is minimal bank and agency use. The RMN Night planned demand confirms that the actual demand is lower, which is indicative of the of RMN’s availability.


The Care Staff Day and Night actual demand is significantly higher than planned, which reinforces the need by the Trust to utilise bank and agency resource to cover vacancies and support the established workforce. The increase demand is primarily due to extra observations and increased patient acuity.

5. Registered Nurse Hours – Substantive v’s Temporary Staff fill rates

The below table shows percentage of hours from April 2016 split by bank hours, agency hours and substantive hours for all registered nurses. Further work is being undertaken to enable this data to be triangulated and ensure we are utilising temporary staffing in the most effective and efficient way.


6. Registered Nurse Hours – Substantive V’s Temp Staff Fill Rate The below table shows percentage of Registered Nurse Hours – Substantive V’s Temp Staff Fill Rate for individual wards. Vacancy rates are impacting on fill rates alongside increased patient acuity requiring increased observations.


7. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates

The below table shows percentage of hours in 2016/17 split by bank hours, agency hours and substantive hours for all care staff. Vacancy levels and increased patient acuity requiring high level observations are impacting on use of temporary staff. There is a slight increase in use of agency staff , this was due to late requests due to changes in staff availability.


8. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates

Further analysis of registered nurse hours by ward for December month is presented in the below table.Vacancy levels and increased patient acuity requiring high level observations are impacting on use of temporary staff.


9. Minimum of two qualified nurses per shift Standard The Trust has an internal safer staffing standard, where there is a minimum of two qualified nurses rostered per shift. The information sourced from HealthRoster shows that in December 2017 across the inpatient areas the overall day and night compliance rates are 87.57%, with 96.77% and 69.18% for night shifts. This data does not include additional staff on the wards who work supernumerary to the shift roster, therefore additional qualified staff including Ward Managers, Night Coordinators are additionally available to support clinical care delivery.


The below table shows the December 2017 Day shift compliance rate by ward:

Where compliance falls below 100%, this is predominantly around short notice sickness. Where there are shortfalls, this is managed by support from the supernumerary Ward Managers, Band 6 who are on supervisory days or bleep holders.


The below table shows the December 2017 Night shift compliance rate by ward: There is significant variance on the compliance. It is evidence that the impact of vacancies and team skill base is leading to one qualified member of staff being rostered into the numbers for nights on wards , however assurance provided by the Head of Service and Ward Managers is that their preference to maintain a safe environment and continuity of care is to utilise experiences HCA staff in some instances. The Head of Service is working with Ward Managers to improve consistency.




Report Title:

Director of Operations Report


Lesley Writtle, Interim Director of Operations


Lesley Writtle, Interim Director of Operations

Purpose of the report: To update the Trust Board on key issues pertaining to service

delivery in the directorate of operations.


Decision / Approval

Gain assurance

Discussion

Information


Committee: None


N/A




Leadership culture






Caring

Service delivery issues relate to all aspects of the CQC domains.


Enc 20 Director of Operations Report january (2) Page 1 of 12

Title Director of Operations Report Introduction The report for the Directorate of Operations aims to update the Board on pertinent issues and challenges relating to operational service delivery. Summary of key points, issues and risks Urgent and Access: Early Access Service (EAS) Mental Health Assessment Service Crisis Resolution teams Psychiatric Liaison and Urgent Care Street Triage Section 136 Suites

Early Intervention: Child and Adolescent MH Services, including i-CAMHS Eating Disorder services Regional Deaf CAMHS service Primary MH Services, including IAPT Early Intervention in Psychosis teams

Community: Community Recovery Services Employment Services Psychological Therapies ‘Hub’ Community MH Teams for Older People Older People Day Services Dudley Memory Assessment Service Walsall Carers’ Service TALCS

Inpatients: All Inpatient Services (4 wards for Older People, 5 wards for working age Adults) Home Treatment Services Bed Management

1) Operational Plans 2018/19 Operational teams are currently reviewing priority work areas for 2018/19; this incorporates focus upon key work areas delivery of recurrent CIP and transformational plans. This will also ensure that the Trust is aware of the work areas we are prioritising and areas we believe there is a risk in delivering due to capacity or factors outside of our control. This work also links to the current contractual negotiations to ensure that we have outcomes that can be achieved and that we are recompensed for performance and activity we deliver. We are also looking at the portfolios that the heads of service hold as described above to ensure that they remain deliverable and there is a logic to areas grouped together. In February we plan to share this work with Clinical Leads to ensure we have a strong joint working approach moving forward. This will then be reported to Trust Board Enc 20 Director of Operations Report january (2) Page 2 of 12

From a contractual perspective, operational services are working closely with finance and commissioners with a particular focus on ensuring acknowledgement of the work we are doing with complex in patients. Also a focus on the ongoing debate about QIPPs that we need to ensure are deliverable between the commissioner and provider, this is of particular concern in Walsall but discussions in the last week seem to have made significant progress . We are optimistic that we have made progress with proposals around special observations in both Boroughs and we have had confirmation of IAPT investment in Walsall. 2) IAPT Director of Operations is chairing a weekly recovery group within the Trust which is looking at a wide ranging set of issues to improve performance, the plan is attached. The plan is looking at detailed performance and trajectory information. We have secured some badly needed analytical support which commences first week of February, BCPFT are going to share knowledge built up around use of current data collection to assist our recording of data, communications have developed a new extensive marketing and communications plan, we have had a small amount of STP money to resource pop up clinics. Business cases have been shared with CCGs to respond to the need to develop the service in response to the external review from last year, Walsall CCG has responded positively and committed to this development with immediate effect. Dudley CCG has issued a Contract Performance Notice for failure to deliver Remedial Action Plans (RAP). Operations, contract and finance are working together to respond. It should be noted that due to the gap in investment it will be impossible to deliver the trajectory requested. The CCG is aware of all the work being undertaken. 3) CAMHS Walsall services are part of a CQC visit regarding safeguarding; early indications and feedback suggest they are impressed with CAMHS and could see progress from September when the same reviewers came for the thematic review. Across the Black Country services are meeting to look at an STP approach and working together this will include CAMHS-Crisis and Eating Disorders in particular. The meetings are progressing well. There is an in house service review of the Deaf CAMHS Service, to reflect on its achievements, gaps, needs, changes especially in view of the additional funding into CAMHS. Looking at national benchmarking and how the service benefits from operating in the hub and spoke model. The outcomes will be shared at the quality and safety committee when complete.


4) Section 75

A formal letter was received by the trust on 22 December 2017 giving notice of termination for 31st March 2018. We are working closely with Walsall CCG Chief Officers to make sure any risks are identified and acted upon; both parties see this situation as a retrograde step in relation to integrated working.

Task and Finish Groups continue weekly for Adult and older adult teams. The Older Adult CMHT is now nearing position for when Social Workers can transition along with discharge of around 116 patients. As Older Adults Mental Health has worked in a less integrated way than CRS the impact of dissolution will appear less of an issue on caseloads but as stated above will impact all of the other areas around rota and OOHs. The potential transfer date for Older Adults CMHT Social Care staff and these patients is planned during February. The main issue currently is how to transfer information onto the social care IT system.

The other aspect of transfer is adult age services this will be far more complex and could have the potential to place a greater burden on health services. Work is underway to confirm and assess caseloads. Work has also commenced with Head of Service and Clinical Director regarding analysis of casework and what health patients can be legitimately discharged. This will link into the current Capacity work. The deadline for this transfer remains 31 March 2018. This work is being undertaken in conjunction with the CCG due to the potential impact upon capacity. There remains concerns about how Housing and Benefits will be addressed as previously our Social Care Support Workers would focus upon this and in the new model this is in doubt. Work is also underway around agreeing the ownership and processes around reviews of 117.

We are going to ensure that there are clear operational polices for the new working arrangements, this will ensure there is clarity regarding responsibilities.

All of this is being reflected in the Risk Assessment

5) Inpatient services Bed Capacity There has been continued pressure within bed management across the Trust for the last 6 weeks with minimal or no Adult beds, the team have put concerted effort into ensuring we have capacity to admit patients. In addition we are doing further work relating to the bed reduction requirements in Older Adults, in line with commissioning intentions. Dudley step down beds have been full since Christmas with some patients successfully being found appropriate placements in a timely fashion, this is improving our relationship with DGOH and the Local Authority. Significant effort was made by the clinical and operational team at the start of this venture to make this a success. Enc 20 Director of Operations Report january (2) Page 4 of 12

Staffing There remains pressure on recruitment and retention of band 5 staff nurses, mainly due to other jobs becoming available across the Trust and staff going for promotion. Rolling recruitment still in place but further meeting organised to look at utilising social media in a more effective way and innovative ways to recruit. It should be noted that thanks to the dedicated staff for their hard work and commitment, especially over the Christmas time and period of bad weather, patient care was not compromised. They have also responded well to supporting staff in both of our acute trusts in very busy circumstances. 6) Liaison and Diversion Services We have bid jointly with BCPFT for services in Worcester, NHSE invited the Trust to West Mercia HQ to discuss some clarification questions they had around our model for service delivery – particular focus on the clinical model and IT issues. We await an official answer. We are drafting a management of change paper regarding the integration of Liaison and Diversion and the criminal justice teams and have been working with Black Country colleagues on this. This would enable closer and more efficient working. Recommendation The Board is asked to note the updates within operation services. Board Action Required To receive the report.


Division: Mental Health Objective: Improving access into IAPT Target Name: Dudley and Walsall IAPT

Breach Type: Not applicable Indicator Type: Local Quality Requirement Responsible Executive:

Lesley Writtle, Director of Operations Divisional Lead: Anne Marie Carey, Head of Early Intervention, Access and Urgent Care

Target Description: Producing a short term recover action plan to achieve the agreed trajectory for the remainder of 2017/18 (see trajectory below).

What issues are the issues for improving access to IAPT (including older adults and BAME) (Please list issues below and add extra lines if necessary)

1

2

3

4

5


What Actions are being taken to resolve the issues ? (Please list actions below and add extra if necessary) Develop business case/recovery action plan for CCG and NHS England with detailed stages of delivery and identified resources required

Relates to Issue (Ref) Owner

Target Completion Date

Actual Completion Date

Status (RAG) Comments

Agree capacity gap using an agreed approach to measuring Demand and Capacity

Anne Marie Carey Capacity and demand work completed using NHSI

Improvement tool: Michael Watson

Final Draft Business Cases for Dudley and Walsall Services to be presented at MEXT

Anne Marie Carey February MeXT Agenda

Final Business Case to be submitted to CCG and NHSE

Jacky O'Sullivan / Lesley Writtle Completed and sent to CCG Leads

Increase Support for Services (Project Management, and Data Analyst)





Liaise with BCPFT to understand current set up and explore potential capacity for Analytical support

James Parker 03/01/2018 02/01/2018 Work undertaken with BCPFT to look at analytical data and role of post. Analyst to start 1/2/18 will collaborate with BCPFT.


Identify project management capacity to support the services and recovery plans

Lesley Writtle / Jacky O'Sullivan 03/01/2018 19/12/2017 Complete

Identify funding for short term Analyst to support the service until the end of March

Lesley Writtle / James Parker 04/01/2018 03/01/2018 Complete

Recruitment of of Analyst if funding is approved

Anne Marie Carey / James Parker

01/02/2018 Feb-18 Commences in service 1/02/18

Increase Access rates Relates to Issue (Ref) Owner




Draft a proposed communications and marketing strategy to identify demand and increase access

Michelle Carr 04/01/2018 03/01/2018 New communications and engagement strategy agreed in working group. This provides a bespoke plan for both Boroughs

Identify funding for access worker Lesley Writtle /

Jacky O'Sullivan 04/01/2018 28/12/2018 STP funding identified which will cover a certain % - additional funds to be identified

Approach both CCGs to match fund the STP (£24k). ie £12k from each - to support the access worker role, and marketing campaigns

Jacky O'Sullivan 11/01/2018 04/01/2018 2 new workers in post.


Roll out agreed communications and marketng strategy

Michelle Carr and service leads

01/03/2018

Comms Strategy meeting scheduled for the 15th January - access worker to be included in the comms plan - mobilisation of an access worker is expected to take up to 2 weeks

Agree realistic trajectrory up until end of March for activity

Anne Marie Carey / Heidi Cole / Lesley Burton / James Parker

15/01/2018 Trajectory submitted

Review current pathway set up, ie load access with capacity, set up new groups, re-establish new groups

Heidi Cole and Lesley Burton 04/01/2018 Weekly activity of review in place

An Organisational response to potential complaints/concerns should waiting times increase as a result of increased access

Lesley Writtle/SED 01/02/2018

Working with SED to ensure they are aware of capacity issues and we have a standard response in place


Service Improvement / Snagging Issues





Escalate and identify IT access issues James Parker 12/01/2018

Ian Mitchell will set up drop in workshops for both Dudley and Walsall services to resolve issues and identify any bigger problems that may require further focus - weekly review

Review business case for IAPTUS Lesley Writtle 08/02/2018

Business Case for IAPTUS (or similar system) to include Data Analyst (to support data cleanse for migration)

James Parker 01/03/2018

Explore issues relating to call waiting system, and identify any potential improvements

Ian Mitchell 01/03/2018

Transfer of Activity: Physical Health IAPT Service





Staff to be seconded from BCPFT 3.6 WTE Anne Marie

Carey 01/03/2018

On Track


Awaiting formal notification from Commissioner to BCPFT

Melvena Anderson 04/01/2018

Activity to transfer to Trajectory following data sharing agreement

Anne Marie Carey

01/02/2018 On Track

Development of Performance Dashboard





Draft Dashboard

James Parker 01/02/2018 Feb-18

Weekly live reporting of Trajectory James Parker

15/02/2018


Monitoring of Short Term Recovery Plan





Development of a regular Dashboard that includes: - Numbers entering treatment as per our figures and national - Treated within 6 weeks - Treated within 18 weeks overall and split by HIT and LI - Recovery rates overall and split by HIT and LI - Completion of IAPT MDS - Monthly sickness absence rate - Monthly IAPT WTE for HIT and PWP - Numbers waiting for access and waiting for treatment - DNA and Cancellation % - Include complaints and concerns

James Parker 18/01/2018

Set up weekly meetings for the recovery group Nicola Lavender 03/01/2018 03/01/2018


Trust Board date: 1 February 2018

Item number: 8.6 Enclosure: 21

Report Title: High Level Operational Risk Register

Accountable Director: Rosie Musson (Acting Director of Nursing)

Author (name & title): Neil Tong (Patient Safety Facilitator)

Purpose of the report: • The purpose of this report is to provide the Trust Board with the Red Risks for the period ending 25 January 2018 and in doing so provides the committee with information on: o Any new red risks being escalated to the High Level

Operational Risk Register o Any red risks being downgraded from the High Level

Operational Risk Register. o Any updates to red risks currently held on the Trust High

Level Operational Risk Register.


Decision / Approval

Gain assurance

Discussion

Information



Committee: The details within this report was reviewed by: • Quality and Safety Committee • Finance and Performance Committee • Workforce Committee

Date reviewed: 10 January 2018 – Quality and Safety Committee 22 January 2018 – Finance & Performance Committee 23 January 2018 – Workforce Committee The risks enclosed within this risk register were approved by Quality and Safety Committee with a number of risks referred to Finance and Performance Committee, Mental Health Act Scrutiny Committee and Workforce Committee in line with the requirements of the Trusts risk management strategy.




Leadership culture




Enc 21 High Level Operational Risk Register Page 1 of 13



Caring Some of the risks held on the register have the ability to directly or indirectly impact upon the care/services offered

Responsive The Trust Wide Risk Register Provides a representation of the Trusts “Red Risks” and the responses to managing/action planning these risks; some (due to the nature of the risk) provide a response to a short term or long term issue

Effective Some of the risks held on the Trust Wide Risk Register impact upon the future viability / effectiveness of the Trusts operations.

Risk FINAN 1 specifically relates to the long term outlook in relation to CIP

Well-led Some risks held on operational risk registers Pertain to issues around service redesign and may have impacts upon leadership and staffing issues

Safe The appropriate management of risk is central to the provision of a quality, safe service. In particular CQC Outcome 16 – Assessing and monitoring the quality of service provision


Title High Level Operational Risk Register Introduction

It is the purpose of this report is to provide the Trust Board with the Red Operational risks held across the Trusts Risk Registers (for the period 25th January 2018) and in doing so provides Trust Board with information on:

• Any new red risks being escalated to the High Level Operational Risk Register. • Any red risks being downgraded from the High Level Operational Risk Register Any

updates to red risks currently held on the High Level Operational Risk Register. There are currently 8 risks being presented as part of this report. This is being done in line with the Trusts risk management strategy and further details of these are included within table 1.1.

Summary of key points, issues and risks There are 8 risks included within this report which are applicable for presentation to the Trust Board. A summary of these risks are detailed within table 1.1. The full details of these risks are articulated in appendix 1 Table 1.1. – Summary of risks

Risk ID

Risk Description

Impacts Opaerationally (and updates)

Status of risk

FINAN 1 Inability to meet CIP targets, funding for Mental Health, QIPP (and in longer term the Dudley MCP) have the potential to impact upon the long term financial viability for DWMH. Issues Include: * CIP and QIPP requirements from existing baselines * Reduction in investment by Local Authorities * In longer term, the Dudley MCP plans can be expected to require on-going efficiencies through internal CIPs * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward (Risk related to long term challenges around CIP and not "In Year Position"

Source – Financially driven risk with quality implications. Existing risk already reported to Quality and Safety Committee

Update This risk includes information in relation to MCP and QIPP requirements and is to remain as a red risk. Further actions have been reviewed and existing controls are reflective of the current position.

=


Risk ID

Risk Description


Status of risk

HR 002 Reduction in Local Authority staffing in mental health workforce due to the ending of the s.75 partnership arrangement with Walsall council. This has the potential to impact on service delivery and place operational pressures on clinical team and operational viability of some front line services.

Source – Risk to quality of service driven by a reduction in local authority funding. Existing risk already reported to Quality and Safety Committee

Update Risk reviewed and updated by Interim Director of Operations and Head of Social Care. Current risk to remain as 4 x 4 = 16 Description of risk has been revised to better reflect the Trusts current position.

A further piece of work is to be completed in relation to understanding the impact this will have upon caseloads and a task and finish group commenced from the end of October 2017

Formal letter of Termination received at the end of December 2017

=

314 The Trust effectively operates two sets of clinical records - paper-based in wards and electronic in the community.

This may lead to an inconsistent approach being taken to clinical risk management, having implications upon continuity of patient care planning and risk management

Furthermore, the decision as to which product is to be procured has been delayed as a result of TCT. The delay reflects an eventual desire to implement a single agreed solution across the TCT trust

Source – Major project already enacted by the Trust to replace existing clinical system. CQC assessment highlighted that interface between electronic and paper system is a clinical risk and as such interim measures are being put in place to mitigate the risk along with long term measures (the replacement of OASIS)

Update Risk has been reviewed description has been updated by the Interim Director of Finance Performance and Estates. Risk was still felt to be a red risk at this present time and is rated as 4 x 4 = 16

=

EF002 Fire Safety Management within the Trust and lack of assurances in respect to certain arrangement regarding fire safety

Source – Gap analysis of assurances undertaken within estates. Issue escalated via Estates Risk Register

Update Risk has been fully updated by the Trusts Interim Director of Finance and is fully reflective of the Trusts fire safety action plan / work plan.

=

289 Lack of a formally of ratified 136 policy, may cause operational difficulties between trust staff and partner agencies (police).

In addition to this the lack of funding for a fully staffed 136 suite (Place of Safety) within the Trust may also lead to a substandard level of service.

Furthermore, the reduction in the duration of section 136 from 72 to 24hr may lead to a breach in the act, where a specialist placement cannot be identified in a timely manner.

Source – Guidance issued nationally as part of the CQCs thematic work into places of safety / 136 suites which led to a national review of section 136 and the Trusts November 2016 CQC visit.

Update Risk reviewed and updated by Head of Social Care. Risk re-worded to better reflect current situation. No changes to risk score.

=


Risk ID

Risk Description


Status of risk

387 Failure to deliver the 2017/18 control total/financial plan for the year as set down by Trust Board and agreed with NHSi The specific elements of risk identified are:- 1.Failure to delivery full CIP 2.17/18 CQUIN 3. Contract penalties 4. Walsall S75 management costs 5.Property rentals 6. Income risks 7. Excess agency costs - nursing 8.Excess agency costs - TCT 9.Other TCT-related costs 10.MERIT under-recovery of income 11.16/17 CQUIN 12.Apprenticeship levy

Source – Risk added following discussion at Finance and Performance Committee. Risk updated by Interim Director of Finance and Performance

Update Risk updated via interim Director of Finance and Performance

Risk to remain on the risk register as a red risk. Further actions have been updated to reflect paper presented to Finance and Performance Committee detailing further actions.

Risk has been downgraded following discussions at F&P committee. Risk has been downgraded from 5 x 4 = 20 to 5 x 3 = 15

=

456 Failure of the Trust to achieve its essential training may result in staff not being appropriately skilled to undertake their role and impact upon the Trust meeting compliance with CQC standards and impact upon the quality of patient care

Source – Discussions at workforce committee and the splitting of risk 323 into an essential training and a mandatory training risk

Update Risk created following the splitting of risk 323 into risks in relation to essential and mandatory training.

=

466 Transition through TCT results in staff from Corporate services feeling disengaged or fearful around their jobs resulting in decreased engagement levels, increased sickness rates and increased turnover

Source – Risk added to risk register and escalated to Trust Board Following agreement at Workforce Committee

New

Further detail (if required) Further details of the risks are outlined in Appendix 1 Recommendation It is recommended that the Trust Board approve the enclosed copy of the High Level Operational Risk Register and approve the risks contained within. Board Action required To approve the risks included within this report and note the action taken to date.


Appendix 1

R isk N o .

R isk D esc rip tion

S o u rce o f R i s k

D a te Iden tified

P r i n c i p l e O w ne r o f R i s k

O t h e r C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tio ns R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f A ssu rance

D a te o f R ev ie w

Fu rthe r C o m m en ts

F INA N 1 Inab ility to m ee t the annua l sav ings ta rge ts se t fo r N HS p rov ide rs .

T h is cove rs bo th 'in te rna l' cos t im p r o v e m e n t requ ire m en ts and 'ex te rna l' (Q U IP P ) re q u ire m e n ts . Issues to no te inc lude :- 1) ) 3 -4 % e ffic iency requ ire m en t has been in p lace fo r a nu m be r o f yea rs , and is like ly to con tinue 2) ) T he T rus t is inc reas ing ly re lian t upon non -recu rren t s o lu tions 3) ) T he D ud ley M CP is like ly to requ ire s im ila r leve ls o f sav ings in the fu tu re 4) ) T he T rus t has exhausted the po ten tia l fo r 'tr a ns ac t ion a l ' so lu tions , bu t is f in d ing ' t r a n s f o r m a t i v e ' so lu tions d ifficu lt to im p le m en t 5) ) C IP p roposa ls tend to be 'top /do w n , ra the r than deve loped by ind iv idua l se rv ices .

F in a nc e P ro jec tions / D a t a

28 /02 /2011

R up e rt D a v i e s

Executive Directors

5 4 R ed

20 D e ta iled deve lop m en t o f cos t im p rove m en t p rog ra m m e

Investm en t in a C IP P M O p ro jec t t e a m 2016 /17 in te rna l aud it rev ie w o f the ope ra tion o f the then C IP P rog ra m m e B oa rd - T rus t im p le m en ted its reco m m enda tions rega rd ing te rm s o f re fe rence and m ode o f ope ra tion . E s tab lished C IP P rog ra m m e B oa rd (no w expanded re m it to cove r g ro w th - C IG P rog ra m m e B oa rd Q ua lity Im pac t A ssess m en ts ca rried ou t on a ll cos t im p rove m en t p ro jec ts A c tive in -yea r m on ito ring fac ilita tes inc reased sc ru tiny w he re C IP s a re n be ing im p le m en ted o r de live red o r w he re a lte rna tive m itiga tions requ ire d e v e lo p m e n t.

5 3 R ed

ot

15 Q IA s shou ld be co m p le ted and s igned o ff be fo re the co m m ence m en t o f the financ ia l yea r to w h ich the C IP re la tes .

B oa rd , M e X T , F&P , and C IP p rog ra m m e B oa rd a ll requ ired to focus upon sche m es no t de live ring /de layed de live ry .

P rocesses shou ld be im p le m en ted so tha t C IP sche m es a re deve loped 'loca lly ' ra the r than im posed upon se rv ice lines by the D irec to r o f F inance as pa rt o f the budge t se tting p roc ess

A tten tion and m u tua l executive suppo rt shou ld focus upon trans fo rm a tiona l sche m es

5 1 G reen

5 V a rious F inance and P e rfo rm ance repo rts inc lud ing :

R epo rts to B oa rd

R epo rts to F & P C o m m i tt e e inc lud ing ind iv idua l ac tion p lans on p ressure a reas .

R epo rts to M EX T

R ev ie w s by ex te rna l assessors inc lud ing T D A , H D D and M on ito r

In te rna l aud it repo rts a round C IP g iv ing fu rthe r as s u ranc e

E x te rna l bench m a rk ing o f p lans

04 /01 /2018

R isk rev ie w ed by A c ting D irec to r o f F inance and P e rfo rm ance and rev ie w ed a t E xecu tive C o m m s M ee ting . R isk to re m a in as a red risk on the H igh Leve l O pe ra tiona l R isk R eg is te r


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




H R 002 R educ tion in Loca l A u tho rity s ta ffing in m en ta l hea lth w o rk fo rce due to the end ing o f the s .75 pa r tne rsh ip a rrange m en t w ith W a lsa ll counc il. T h is has the po ten tia l to im pac t on se rv ice de live ry and p lace ope ra tiona l p ressures on c lin ica l tea m and ope ra tiona l v iab ility o f so m e fron t line s e r v i c e s

F eedback F ro m S takeho lde rs / P

30 /05 /2012

L e s l e y W r i t tl e

Rosie Musson

Hassan Omar

4 4 R ed

16 S ec tion 75 ag ree m en ts p rov ide fo rm a l p la tfo rm as the bas is fo r any fu rthe r nego tia tions in fund ing and resou rce changes

Jo in t app roach ag reed w ith W a lsa ll M B C rega rd ing im p le m en ta tion o f fund ing reduc tions . R isk A ssess m en ts on loss o f pos ts has been co m p le ted R egu la r d iscuss ions be ing he ld a t P a rtne rsh ip O pe ra tions G roup . A dd itiona l sho rt te rm capac ity has been co m m iss ioned

F u rthe r w o rk w ith CC G on risks associa ted w ith loss o f soc ia l ca re s ta ff and e ffec t on case load

4 4 R ed

16 D e ta iled p iece o f w o rk to be co m p le ted in re la tion to the im pac ts th is is hav ing / w ill con tinue to have upon case loads

D iscuss ions ongo ing a t P O G (M on th ly ongo ing bas is )

T a sk and fin ish ove rs igh t g roup to s ta rt fro m end o f O c tobe r 2017 to ove rsee w o rk and repo rt to T rus t and C o u nc il

4 2 A m be r

8 R epo rts to M EX T

U pda tes to B oa rd

04 /01 /2018

R isk rev ie w ed and upda ted by A c ting D irec to r o f O pe ra tions and H ead o f S oc ia l C a re . C u rren t risk to re m a in as 4 x 4 = 16 D escrip tion o f risk has been tw eaked to be tte r re flec t the T rus ts cu rren t pos ition . A fu rthe r p iece o f w o rk is to be co m p le ted in re la tion to unde rs tand ing the im pac t th is w ill have upon case loads and a task and fin ish g roup is co m m enc in fro m the end o f O c tobe r

g


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




314 T he T rus t e ffec tive ly ope ra tes tw o se ts o f c lin ica l reco rds - pape r-based in w a rds and e lec tron ic in the c o m m u n i t y .

T h is m ay lead to an inconsis ten t app roach be ing taken to c lin ica l risk m anage m en t, hav ing im p lica tions upon con tinu ity o f pa tien t ca re p lann ing and risk m anage m en t

F u rthe rm o re , the dec is ion as to w h ich p roduc t is to be p rocu red has been de layed as a resu lt o f T C T . T he de lay re flec ts an even tua l des ire to im p le m en t a s ing le ag reed so lu tion ac ross the T C T trus t

F eb 2016 C Q C V is i t

19 /05 /2016


IM&T David Crook

4 4 R ed

16 R ev ie w o f risk assessm en t te m p la te has been co m p le ted in line w ith CP A requ ire m en ts to ensu re tha t s ta ff p rac tice is in line w ith bes t p rac tice T ra in ing needs ana lys is has been looked a t ac ross the T rus t to ensu re tha t inpa tien t s ta ff can upda te e lec tron ic risk assessm en ts on O A S I C onsu lta tion w ith ove r 60 c lin ica l an c lin ica l ad m in s ta ff to deve lop the bus iness case and spec ifica tion fo r the ne w c lin ica l sys te m has been unde rtak en S upp lie rs have sub m itted responses to the Inv ita tion to T ender (ITT ) Inpa tien t a re be ing tra ined to upda te FA C E risk assessm en ts on the O A S sys te m , to ensu re tha t co m m un ity s ta ff a re a w a re o f risks w h ich m ay have e m e rged du ring the pa tien ts inpa tien t s tay R e fe rence S ite V is its have occured S ys te m D e m ons tra tions unde rtaken C lin ica l engage m en t is be ing pu rsue ac ross the T C T pa rtne rsh ip (by w ay o f the c lin ica l w o rks trea m s ) w ith a ne w p roposed ro ll-ou t p lanned fo r O c tobe r 2018

s4 4 R ed

S

d IS d

16 A m ee ting has been a rranged w ith B CP F T and B C HCF T by the In te rim D irec to r o f F inance in respect to tak ing th is fo rw a rd / re -s tab lish ing t im e l ine s .

In te rim D irec to r o f F inance a lso to con firm in w riting w he the r the tende ring p rocess unde rtaken las t yea r has lega lly ended .

F u ll bus iness case app roved and con trac t s igned

R o ll ou t o f ne w c lin ica l sys te m c o m m enc es

Iden tifica tion o f p re fe rred supp lie r

Q ua lity im p rove m en t p rio rity in re la tion to "Im p rov ing the Q ua lity o f reco rd keep ing " and P e rson C en tred C a re P lann ing " to be unde rtaken th roughou t the 2017 /18 yea r.

4 2 A m be r

8 R epo rts to M E x T R epo rts to IG IM & T co m m ittee

04 /01 /2018

A m ee ting has been a rranged w ith B CP F T and B CH CF T by the In te rim D irec to r o f F inance in respect to tak ing th is fo rw a rd / re -s tab lish ing t im e l ine s .

In te rim D irec to r o f F inance a lso to con firm in w riting w he the r the tende ring p rocess unde rtaken las t yea r has lega lly ended .


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




EF002 F ire S a fe ty M anage m en t w ith in the T rus t

E x is ting R epo r ting S y s t e m s

19 /05 /2016


Phil Clark STK (Fire Safety Advisors)

Marsha Ingram

Rosie Musson

Neil Tong

5 4 20 R ed

A ll s ites m a in ta ined by the T rus t have a spec ific F ire R isk A ssess m e in P lace . P P M s a re in p lace as requ ired by H T M s A ll m a ttresses a re 5 and o r 7 C rib ra te d . M anda to ry tra in ing is in p lace . F ire S a fe ty P o licy has been upda ted and re -ra tified N u m be r o f fire requ ired fire m a rsha ls has been iden tified A D T and M id w es t F ire S e rv ices hav been co m m iss ioned to p rov ide a se rv ice w h ich add resses so m e o f th gaps in assurance . S u itab le and su ffic ien t assessm en t fire risk assessm en ts to be unde rtaken a long w ith an aud it o f doc u m en ta tion . G rade 1 w o rks fro m fixed w ire tes tin has been co m p le ted . P A T tes ting p rog ra m in p lace E xa m ina tion o f ex te rna l (s truc tu ra l) and in te rna l (su rge p ro tec tion ) co m ponen ts ce rtified . R ou tine tes ting o f fire de tec tion and w a rn ing sys te m s in p lace . P o rtab le fire app liance inspection reg im e in p lace w ith A bbey fire C o m pa rtm en ta tion su rveys c o m p le ted A ud it tra il in p lace in re la tion to s m oke and fire da m pe rs . A ud it o f cu rta ins , d rapes and b linds have ensu red tha t ag reed s tanda rds a re be ing m e t in re la tion to fire s a f e t y .

5 3 15 nts R ed

e

e

o f g

P rog ra m o f m a ttress rep lace m en t to be co m p le ted to ensu re tha t a ll m a ttresses a re ra ted as C rib 7 ongo ing . E s ta tes cu rren tly w o rk ing w ith ope ra tiona l s ta ff to ensu re th is s tanda rd is be ing m e t w ith in acu te inpa tien t a reas (Janua ry 2018 )

P rog ra m o f fire doo r rep lace m en t fo r the D o ro thy P a ttison S ite cu rren tly ongo ing . P rinc ip le fire doo rs a t D P H has been co m p le ted fu rthe r w o rk ongo ing w ith ope ra tiona l co lleagues to ensu re rep lace m en t o f bed roo m doo rs (A p ril 2018 )

A m ee ting has been a rranged and is se t to go ahead on the 11 /01 /2018 in re la tion to the p rog ra m o f doo r ins ta lla tion ac ross the D P H s ite . The a im o f the m ee ting is to ensu re tha t the re is a coo rd ina ted response in re la tion be tw een es ta tes , the con trac to rs and ope ra tiona l s ta ff.

P A T T e s ting po licy to be deve loped and ra tified (Janua ry 2018 )

A n independen t rev ie w o f the T rus t's po lic ies and p rocedu res , ro les and responsib ilities , tra in ing and deve lop m en t, risk assessm en t, asset m a in tenance , res ilience , e m e rgency p lann ing and bus iness con tinu ity p lann ing in respect o f fire risks (Feb 2018 )

5 2 10 A m be r

S T K F ire M anager

F ir e c o m p a r tm e n ta tio n a s s e s s m e n ts

F ire R isk a s s e s s m e n ts

T ra in ing figu res

04 /01 /2018

R isk upda ted based upon d iscuss ion a t the T rus ts F ire S a fe ty G roup 01 /12 /2017 . A m ee ting has no w been a rranged w ith E s ta tes , O pe ra tiona l S ta ff and C on tac to rs in re la tion to ho w bes t to unde rtake the ins ta lla tion o f fire doo rs a t DP H and ho w bes t to m in im ise d is rup tion .


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




289 Lack o f a fo rm a lly o f ra tified 136 po licy , m ay cause ope ra tiona l d ifficu lties be tw een trus t s ta ff and pa rtne r agenc ies (po lice ).

In add ition to th is the lack o f fund ing fo r a fu lly s ta ffed 136 su ite (P lace o f S a fe ty ) w ith in the T rus t m ay a lso lead to a subs tanda rd leve l o f s e r v i c e .

F u rthe rm o re , the reduc tion in the du ra tion o f sec tion 136 fro m 72 to 24h r m ay lead to a b reach in the ac t, w he re a spec ia lis t p lace m en t canno t be iden tified in a tim e ly m anne r.

E x is ting R epo r ting S y s t e m s

15 /10 /2015

L e s l e y W r i t tl e

Rosie Musson, Hassan Omar, Anne-Marie Carey

4 4 R ed

16 A w o rk ing d ra ft is cu rren tly in use an is cu rren tly be ing consu lted on It is the in ten tion tha t on ly 1 doc to r and an A M HP w ill be requ ired fo r a S ec tion 12 and an A M H P . P a rtne rsh ip G roup had s igned o ff the 136 po licy in the m a in In itia l d iscuss ions have been had be tw een H ead o f S oc ia l C a re , the P a tien t S a fe ty and C o m p liance T ea and the W es t M id lands P o lice M en ta l H ea lth Lead rega rd ing p rog ressing the in te ragency ope ra tiona l po licy

d4 4 16 R ed

W o rk has co m m enced w ith T C T pa rtne rs to look a t ho w the nu m be r o f 136 su ites can be s trea m lined and fu lly s ta ffed .

R e m a in ing issues w ith the po licy a re s til l to be reso lved , na m e ly the s ta ffing o f 136 su ites and the re tu rn ing ho m e o f non -ad m itab le pa tien ts

4 1 G reen

4 P a rtne rsh ip G roup M ins

24 /01 /2018

R isk rev ie w ed and upda ted by H ead o f S oc ia l C a re . R isk re -w o rded to be tte r re flec t cu rren t s itua tion . N o changes to risk sco re .


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




387 F a ilu re to de live ry the 2017 /18 con tro l to ta l/financ ia l p lan fo r the yea r as se t do w n by T rus t B oa rd and ag reed w ith N H S i

T he spec ific e le m en ts o f risk iden tified a re :- 1 .F a ilu re to de live ry fu ll C IP 2 .17 /18 CQ U IN 3 .C on trac t pena lties 4 .W a lsa ll S 75 m anage m en t cos ts 5 .P rope rty ren ta ls 6 .Inco m e risks 7 .E xcess agency cos ts - nu rs ing 8 .E xcess agency cos ts - T C T 9 .O the r T C T -re la ted c o s t s 10 .M E R IT unde r-recovery o f inc o m e 11 .16 /17 C Q U IN 12 .A pp ren ticesh ip levy

F in a nc e P ro jec tions / D a t a

01 /05 /2017


Executive Team

5 4 R ed

20 T he T rus t ope ra tes a fu ll range o f financ ia l con tro ls des igned to ensu re financ ia l p rob ity , va lue fo r m oney a ach ieve m en t o f ta rge ts . K ey con tro inc lude - financ ia l p lan es tab lished , devo lved budge ta ry con tro l, rigo rous repo rting on m on th ly bas is to budge t ho lde rs and B oa rd , S F Is and associa ted financ ia l po lic ies an d p rocedu res , and the ope ra tion o f the C IG (fo rm e rly C IP ) P rog ra m m e B oa r

5 3 nRded d

15 F o r each o f the 12 risk e le m en ts iden tified ac tion p lans a re requ ired to e lim ina te (o r w he re tha t is no t possib le ) reduce the leve l o f risk fac ing the T rus t. N o t a ll the risks a re like ly to c rys ta llize , bu t a m on th ly upda te to F&P on ac tions taken /im pac t/ac tions ou ts tand ing w ill be es tab lished

F u rthe r to the p lan the fo llo w ing ac tions a re be ing im p le m en ted to b ring the fo recast ou ttu rn back to p lan : - C lose do w n on con trac t nego tia tions re la ting to s tep do w n beds - C on tinued m on ito ring and m anage m en t o f bank and agency spend ing - R ev ie w use o f pa tien t transpo rt - Inc rease kno w ledge o f ava ilab ility o f beds to ra ise non con trac ted inco m e - N ego tia te w ith DC CG to seek c red it fo r pena lty cha rge a round 2016 /17 IA P T fine - C lose do w n on d iscuss ions w ith P rop C O and loca l CCG S - C on tinued m on ito ring and m anage m en t o f M E R IT inco m e / ex pend itu re - S eek suppo rt o f NH S I re B S I regu la to ry change rega rd ing app ren ticesh ip levy - M in im ize risks to unde r-de live ry o f C Q U IN inco m e - C ap ita l p lan ; rev ie w ou ttu rn to ca lcu la te dep rec ia tion and P D C - Iden tify oppo rtun ities fo r b ring ing ite m s fo rw a rd fro m 2018 /19 C IP p lan - B a lance shee t rev ie w , Iden tify ite m s tha t can be w ritten back to I& E

5 1 G reen

5 M on th ly financ ia l repo rting to F & P and th rough to B oa rd

27 /11 /2017

R isk rev ie w ed and upda ted fo llo w ing d iscuss ion a t F & co m m ittee . R isk to be do w ng raded to 5 x 3 = 15

P


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




456 F a ilu re o f the T rus t to ach ieve its essentia l tra in ing m ay resu lt in s ta ff no t be ing app rop ria te ly sk illed to unde rtake the ir ro le and im pac t upon the T rus t m ee ting co m p liance w ith CQ C s tanda rds and im pac t upon the qua lity o f pa tien t ca re

W o r k f o r c e S t a t is t ic s

05 /10 /2017

A sh i W il l ia m s

Becky Temple-Purcell

Department Managers

4 4 R ed

16 C lose w o rk ing be tw een HR /L D and O pe ra tions F a ce to face tra in ing and E -Lea rn ing av a ilab le T e lephone book ing sys te m ava ilab le fo r m anda to ry tra in ing . H o w to gu ides fo r e -lea rn ing ava ilab le to a ll s ta ff W o rk fo rce repo rts m on ito red a t F&P , W F C , M E X T & B oa rd . W eek ly co m p liance repo rts sen t to MEXT A p iece o f w o rk to rev ie w th is has been unde rtaken by executive c o m m s

4 4 R ed

16 A pp roach fo r each E T to reach co m p liance be ing taken

E xecu tive D irec to rs to be assigned to each E T co m pe tency

4 1 G reen

4 W o r k f o r c e r e p o r ts /s ta t is t ic s

W o r k f o r c e C o m m i tt e e

19 /12 /2017

R isk rev ie w ed and upda ted v ia W o rk fo rce C o m m ittee N o changes to risk . C u rren t essentia l tra in ing figu res a re be lo w the T rus t ta rg e t


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




466 T rans ition th rough T C T resu lts in s ta ff fro m C o rpo ra te se rv ices fee ling d isengaged o r fea rfu l a round the ir jobs resu lting in dec reased engage m en t leve ls , inc reased s ickness ra tes and inc reased tu r n ov e r

W o r k f o r c e S t a t is t ic s

01 /12 /2017

A sh i W il l ia m s

Trust Executive Team

4 4 R ed

16 T C T In teg ra tion B oa rd es tab lished In te rna l C o m m un ica tion channe ls ava ilab le inc lud ing T ea m B rie f, A sk C E O , W eds W ire , E ng C ha m p ions , FS UG /S ta ff E ng Lead H & W b P lan in p lace to suppo rt s ta ff

4 4 R ed

16 C o m m s & E ng P lan fo r T C T to be dev e loped O D P lan fo r T C T to be deve loped

Leade rsh ip D ev fo r M anage m en t in deve lop m en t to he lp suppo rt s ta ff th rough change

4 1 G reen

4 15 /12 /2017

R isk added to the risk reg is te r fo llo w ing d iscuss ions a t w o rk fo rce c o m m i tt e e .


Meeting date: 1 February 2018


Report Title:

Board Assurance Framework (BAF) – Quarter 3 2017/18

Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary

Purpose of the report: To present the Board Assurance for discussion and provide assurance to Board that the risks are being appropriately managed.

Action required from the Board Decision / Approval

Gain assurance

Discussion

Information


Committee: Finance & Performance Committee, Workforce Committee and Quality & Safety Committee, Date reviewed: 10 January 2018, 22 January 2018 and 23 January 2018 respectively


All the Committees were assured that the Strategic Risks were being appropriately managed. The Quality & Safety Committee discussed delivery of the existing estates plan, and whilst it didn’t affect the Committee’s view that the risk was being managed appropriately have requested further assurance through a report at its next meeting on the activity to deliver that plan. The discussions at the various Committees are reflected in the report and captured as appropriate in the Appended BAF at Quarter 3. The Workforce Committee consider that the risk in the Trust’s ability to recruit and retain staff has increased to a Red RAG rated risk, largely due to anecdotal evidence and real examples of particularly Corporate staff leaving the organisation because of the uncertainty of the TCT partnership.




Leadership culture




Enc 23 BAF2017-18-Q3 Page 1 of 8



Caring

The Board Assurance Framework covers all of the CQC domains.



Title Board Assurance Framework (BAF) – Interim Quarter 2 – Quarter 3 2017/18

Introduction The Board Assurance Framework for 2017/18 was reviewed and revised through discussion at Board Development Session on 30 March 2017. The risks included in the Board Assurance Framework have been agreed through the Board Development Session as those strategic risks to the delivery of the Trusts overarching priorities. Within the reporting process the Committees of the Board have a significant role in monitoring the strategic risks within their Terms of Reference to ensure that they are being managed effectively and provide assurance through that work to the Board. Summary of key points, issues and risks A more comprehensive summary of the issues around the reported risk are included in each risk template which encompasses:

• Initial and mitigated risk score • The origins of the risk • Impact on CQC domains and risk consequences • Risk Controls and reporting Mechanisms • The positive assurances received • The Gaps in Control and Assurance mechanisms and any actions to address those

gaps The initial and mitigated risk scores have been calculated using the matrix in the Trusts Risk Management Strategy. The Assurance Framework at the interim period between Quarters 2 and 3 has been comprehensively reviewed and prepared in discussion at the Quality and Safety, Finance and Performance and Workforce Committees respectively. All the Committees have confirmed that they remain assured that the strategic risks on the BAF within their remit are being appropriately managed. The BAF and the Operational Risk Register The BAF and the operational risk register should be aligned such that the high red rated operational risks inform the development of the BAF at the start of the financial year, and therefore the Board will see the high level red rated risk reflected in the origins of and gaps in either the control or assurance of the Strategic risks in the BAF. Further detail The Board Assurance Framework at Quarter 3 2017/18 is appended to the report.


The tables below outline the movements in the Strategic risks at the end of quarter 3: SR1 – Sustainability of the Organisation Gaps in Control / Assurance The Benefits realisation plan for the TCT partnership

has been developed and will need completion as the date for integration following the further pause is known; therefore the deadline of this action has been extended.

The actions to work closely with partners in Dudley and Walsall on proposals for the Dudley MCP and the Alliance Model in Walsall are ongoing and therefore the dates for these two actions have been amended to reflect that.

The deadline for the actions following the further pause in the integration of the Trust’s under the TCT partnership has been amended to reflect the Moving Forward plan being agreed by the partner Trusts and NHSI.

An additional gap in assurance has been identified in terms of resourcing change and the approach to partnerships and actions with timescales identified to address that gap.

Assured Level Q1

2017/18

Assured Level Q2

2017/18

Assured Level

Q2-Q3 2017/18

Assured Level Q3

2017/18

Assured Level Q4

2016/17

Trend in Assured Level

12 12 12 12 12 On the basis of the review at quarter 3 it is not proposed to alter the current risk and rating against this risk. SR2 – Financial Sustainability Origin of Risk The higher than target vacancy rate and reliance on

agency staff is highlighted as an origin of this risk, however the Trust is now operating within the target and receives regular reports regarding compliance with the agency cap, which now reduces the impact of this risk origin

Gaps in Control The identity of mitigation plans for high risk CIP schemes and review of the financial outturn is ongoing and will remain ongoing through the remainder of the year and monitored through Finance & Performance Committee and therefore the deadline for this action has been amended to reflect that.

The action in developing the Cost Improvement Programme for 2018/19 has been amended to reflect that this will be done in line with the Trust’s own business planning timeline, with reference to the TCT process. The review of joint schemes in Mental Health and


CAMHS will continue through the development of the CIP for 2018/19 and therefore the deadline has been amended.

The work with partners on proposals for the Dudley MCP and the Alliance Model in Walsall is ongoing and therefore the gap, action and deadline has been amended to reflect that

Assured Level Q1

2017/18

Assured Level Q2

2017/18

Assured Level

Q2-Q3 2017/18

Assured Level Q3

2017/18

Assured Level Q4

2016/17


16 16 16 16 12 The longer term financial sustainability of the Trust was a driver for the integration of the three Trusts, therefore the development of a financial plan for 2018/19 and identification of CIP Plans to deliver a plan is crucial to maintain the stability of the Trust in the period leading to the integration of the trusts under the TCT Partnership. On that basis therefore, the review at quarter three proposes to maintain this risk at a score of 16 Red rated. SR3 - Achieving quality of care Gaps and Negative Assurance An amendment has been made to reflect the current

position in delivering the CQUIN’s in 2017/18. The action to address the rolling out of the of availability of essential skills training for clinical posts has been updated to reflect the proposal to amalgamate Statutory / Mandatory and Essential training into individual plans for staff members / groups of staff from April 2018.

Assured Level Q1

2017/18

Assured Level Q2

2017/18

Assured Level

Q2-Q3 2017/18

Assured Level Q3

2017/19

Assured Level Q4

2016/17


8 8 8 8 8 On the basis of the review at quarter three 2017/18, it is proposed to maintain the existing level of assurance. SR4 – Ability to recruit and retain staff Origin of Risk The Trust is now operating within its target vacancy

rate, and therefore the impact of this factor on the risk materialising has reduced and therefore moved from amber to green

Control Two additional risk controls have been added. The Workforce Development Plan, which whilst in place is being reviewed and the Locum Agency Protocol and Proforma that was agreed at Board in October 2017.

Reporting Mechanisms The Workforce Committee is now embedded in the governance structure and feedback indicates it has been an effective driver for the workforce agenda.

Positive Assurance Additional positive assurance has been received that


the recruitment KPI’s have now been agreed through the Workforce Committee and are being monitored by that Committee.

Gaps in Control The action to address the effectiveness of the recruitment process has been partially delivered and positive assurance received about that, the use of the recruitment system still needs to be embedded into the Trust’s Recruitment Policy and the deadline for this action has been altered. Part of the action to address the retention of staff that might leave the organisation because of the TCT partnership to identify key posts and recruitment to them is ongoing and therefore the deadline has been amended to reflect that. The action to review vacant posts and prepare to recruit to those as appropriate has been included in a piece of work to identify and address capacity issues across the TCT partners as a result of the further pause in integration. The cross referencing of these plans is being undertaken before being considered by the Integration Board and therefore the timeline for this action has been amended The actions to address recruitment through the deanery and of middle grade Doctors has been completed and the approval of the locum agency protocol indicated as an additional, albeit yet to be tested control.

Assured Level Q1

2017/18

Assured Level Q2

2017/18

Assured Level

Q2-Q3 2017/18

Assured Level Q3

2017/18

Assured Level Q4

2016/17


12 12 12 16 12 The Workforce Committee reviewed this risk on the basis of maintaining the risk score at a score of 4 x 3 (12) Amber Risk. However whilst the Committee were assured that the immediate risks in connection with recruitment to clinical vacancies had been mitigated in the short term, the risk remained. In addition there is increasing anecdotal evidence and real examples of vacancies occurring and increasing in corporate services that support the front line delivery of services. Capacity plans are in development to mitigate against this but until evidence is received that they were mitigating this risk, on the basis of the interim review between at quarter three it is proposed to escalate the risk to a score of 4 x 4 (16). SR5 - Management, Maintenance and Strategy for the Estate Origins of the risk Three additional origins of this risk have been

identified and added, aligning to the discussion at the meeting of the Quality & Safety Committee in December: • Gaps in strategic and operational management • Lack of front-line staffing within the department


• Completion of PAM in autumn 2017 has identified a wide range of improvements required.

Controls Given the additional origins of risk in terms of capacity within the team the strength of the implementation of the Estates Plan agreed through Board as a control mechanism has been highlighted red. An additional control is being put in place to add capacity and leadership within the Estates Team through a Service Level Agreement with one of the Trust’s TCT Partners. The previous controls identified as appointed Independent Engineer for Water Management and authorising Engineer in place for Electrical Safety have been rephrased as appointment of relevant authorised persons. The Premises Assurance Framework (PAM) which includes a checklist to work to has been included as an additional control against this risk.

Gaps and Negative Assurance The deadlines to deliver a number of the actions in addressing the identified gaps in assurance have been extended reflecting the leadership and capacity gap within the estates department. The completion and agreement of the Service Level Agreement (SLA) for Estates support between the parties is included as a gap in assurance until it has been signed off.

Assured Level Q1

2017/18

Assured Level Q2

2017/18

Assured Level

Q2-Q3 2017/18

Assured Level Q3

2017/18

Assured Level Q4

2016/17


16 12 16 16 12 On the basis of the review at quarter three 2017/18, it is proposed to maintain the level of assurance as a red risk to the Trust. The Committee has requested a progress report to its next meeting on the Trust’s delivery of its estates plan. SR6 – TCT Integration Control A TCT Moving Forward Plan has been developed and

submitted to NHS Improvement following the second pause in the integration date to review and reset progress towards integration and provide a framework for partners to work to towards integration. The control is amber rated until the plan has been agreed by all partners.

Positive Assurance The appointment of a Chief Executive to Birmingham Community Healthcare NHS Trust, a process which members of the Board at Dudley & Walsall Mental Health Partnership NHS Trust were engaged in, has been confirmed.


Gaps in Control / Assurance The Heads of Terms of the Partnership outline how the costs of the Partnership will be agreed through the Integration Board, in light of the newly developing approach to the TCT partnership through a ‘Compact’, this gap in assurance is no longer prevalent. The actions and associated deadlines to address the amended gap of a further pause in the TCT integration date have been amended and added to. The action to clarify the Clinical Leadership and Clinical Governance Model supporting Board to Ward visibility proposed for the enlarged organisation is an integral part of the TCT Moving Forward Plan and assurance sought through NHSI and therefore this gap in assurance is incorporated into the action in agreeing and delivering the Moving Forward Plan.

Assured Level Q1

2017/18

Assured Level Q2

2016/17

Assured Level

Q2-Q3 2017/18

Assured Level Q3

2017/18


12 16 16 16 This risk has been added to the Board Assurance Framework for 2017/18 hence the trend is only for the current year. The level of assurance was decreased at quarter 2 given the initial pause in the integration date. it is proposed to maintain the existing level of assurance at a score of 4 x 4 (16) at Quarter 3 given the further pause and whilst the TCT Moving Forward Plan is agreed and delivered by the partners. Recommendation

• That the Board be assured that the Strategic Risks that form the BAF are being managed appropriately.

Board action required The Board is asked to:

• Review the Board Assurance Framework at quarter 3 – 2017/18


Enc 23 BAF2017-18-Q3FinalDraft Page 1 of 1

Dudley & Walsall Mental Health Partnership NHS Trust

ASSURANCE FRAMEWORK

QUARTER 3 - 2017/18


Ref. Strategic Risk Executive Director Board Committee Meeting Date

SR1 Sustainability of the Organisation Chief Executive Board 01-Feb-18

SR2 Financial Sustainability Director of Finance Finance & Performance Committee 22-Jan-18

SR3 Achieving quality of careDirector of Nursing and OperationsJoint Medical Director

Quality & Safety Committee 10-Jan-18

SR4 Ability to recruit and retain staff Director of People and Corporate Development Workforce Committee 23-Jan-18

SR5 Management, Maintenance and Strategy for the Estate Director of Nursing, Operations and Estates Quality & Safety Committee 10-Jan-18

SR6 TCT Integration Chief Executive Board 01-Feb-18

All Overall Assurance Company Secretary Audit Committee 19-Mar-18

All Overall Assurance Company Secretary Trust Board 01-Feb-18

Dudley & Walsall Mental Health Partnership NHS Trust

ASSURANCE FRAMEWORK

CONTENTS


REFQ1 REFQ2

Q2/Q3 A1

Q3 A2Q4 A3

REF A4A5

A6

A7A8A9

A10A11A12A13A14A15A16A17A18

REF RAG A19O1 Red A20O2 AmberO3 AmberO4O5O6O7 REF DEADLINEO8O9O10

REF RAG REF FREQUENCY RAG

DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2017/18

STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 5 x 3 = 15CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4 x 3 = 12What is the strategic risk to be controlled?

Trend in Assured

Level

Partnership Report Trust Board

EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence

be located?

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Annual Plan Approved Trust Board

STRATEGIC RISK

SR1 Sustainability of the Organisation Chief Executive Board Amber

POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / Meeting

Approved Memorandum of Understanding for MERIT and TCT Partnership and Dudley MCP Trust Board

Transform Services to improve the patient Experience and the quality of services

What are the key potential consequences (up to 4) of the risk? Approved Budget for 2017/18 Trust Board

PC1 There would be a gap in the provision of services to patients that would have implications across the whole of the local and regional health economy.

NHS Improvement - Single Oversight Framework - Segmentation 2 IDM

PC3CQC Inspection Report CQC Website

Sign off of the 2016/17 accounts and 2016/17 annual report as a "going concern" Audit Committee

Become the preferred provider of prevention and recovery services for mental health and wellbeing within Black County and beyond

Sign off of the 2017/18 CIP plans and quality impact assessments Trust Board

PC2Agreed Contracts with the Trust's two main Commissioners Trust Board

Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CREWS domains QGAF / BGAF review under the Well-Led Framework Board Development / Trust BoardAll Domains PC4

CIP/PMO & PMO/Business Growth Reports Trust BoardService Development Business Cases MExTResearch and Development Annual Report Q&S Committee & Trust Board

Potential or actual origins that have led to the risk… IMPACT LEVEL

Report to Finance and Performance Commiteee - Month 12 Position Finance and Performance Committee

ORIGINTrust’s ability to influence, pick up and respond to local and national external drivers for change

What are the most significant origins (up to 10) which could or have led to the risk?Red

AmberGreen

GAP ACTION PLAN

G1 Implementation of the Annual Plan Action Plan Plan is in place with quarterly milestones and reporting ro Board

Ability to influence the commissioning of services that allow the Trust to be the preferred provider of Mental Health / well being services Obstacles to innovation, growth and development opportunities The GAPS IN CONTROL / NEGATIVE ASSURANCES are…

What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?

Strength

What are the key controls (up to 10) that are in place to mitigate these risks?

RedAmberGreen

What are the key reporting mechanisms (up to 10) that will provide assurances that the key controls are effective? (E) = External assurance.

RedAmberGreen

G3

Jun-18

G2 Benefits Realisation through Partnership Working Partnership Workstream Scoping and delivery of workstream actions

Nov 17

July 18The risks are CONTROLLED by… Strength The REPORTING mechanisms are…

Understanding challenges in Walsall to improve partership Continue to be an active member of the Partnership Board

March 17Sept 17Jan 18Mar 18

C2 MERIT Vanguard Partnership Green R2 Management Executive Team Meetings Monthly

C1 CIP Service Development PMO Green R1 Trust Board (and Board Development) Monthly

GreenG5 Delay in TCT Transaction Date See Gapin Assurance and actions under

Strategic Risk 6Dec 18July 18

CONTROL REPORTING MECHANISM

G4 Understanding MCP model and requirements of the procurement process

Work with partners on proposals under the the procurement process to deliver the MCP model

March 17Sept 17Jan 18Mar 18

Green

C4 Healthy Walsall Partnership Amber R4 Board Sub Committees Generally Monthly

4 weekly AmberC3 Transforming Care Together (TCT) Partnership Amber R3 CIP Programme Board

Green

C6 Financial & Annual Business Planning Process Green R6 NHSI IDM (e)

C5 Dudley MCP Vanguard Partnership Red R5 Workforce Committee

Quarterly Green

G7Green

AmberReview of Executive Team Capacity Mar-18

MonthlyResourcing change and approach to partnershipsG6

Agree the Business Continuity Plans across the Trust Mar-18

C8 Business Growth PMO Amber R8 Healthy Walsall Partnethip Board (e) Monthly / 6 weekly

C7 Research and Development Strategy Green R7 MERIT & TCT Partnership Boards (e) Monthly / 6 weekly

GreenG8

C10 Standardised Project Management Approach supported by the CIP, QIPP and Partnership (CQP) Programme Board Green R10

G9

C9 Sustainabilty and Transformation Plan Amber R9


REFQ1 REFQ2

Q2/Q3Q3Q4 A2

REF A3A4

A5

A6A7A8A9

A10

A11A12A13A14A15A16A17

REF RAG A18O1 Amber A19O2 AmberO3 RedO4 AmberO5 Red O6 GreenO7 Red REF DEADLINEO8 RedO9

O10


G7

Strength

RedAmberGreen

Developing the programme in line with our own planning timetable and with reference the TCT process and timeline

Green Clarification on the Dudley MCP Delivery model and vehicle and the alliance model of care in Walsall

Work with partners on proposals under the the procurement process to deliver the MCP model and the model in Wallsall

GreenG6

Review schemes that were proposed to be joint schemes in Mental Health and CAMHS with one of the partners to consider their continued viability in light of the pause in TCT integration

G3

G2 In year Cost Pressures Identify / Monitor and mitigate as part of the in year financial plan

Amber

Identification of CIP schemes for 2018/19

Operation of tariff requires internal efficienciesDifficult Contract Negotations with CCG's inluding CCG QIPPsContracts are predomianely block therefore overactivity not paid for

Agency Use Escalation and Monitoring Process


RedAmberGreen


CCG Contract Review Meetings (e)

MonthlyMonthly Returns to NHS I & NHS I IDM (e)

Monthly

C5 STP Cost Improvement Programme Amber R5 Trust Board

C3


C1

Challenge to deliver annual CIP target

C2

quarterly

C9 R9 CIP Programme Board 4 weekly

C8

G9C10 R10 PMO fortnighly meeting - review

schemes

R8

2 weekly Green

Amber

G8

Mar-18

Monthly

C6 Green

G4

Green

R6 Internal and External Audit (e) Ad-hoc Green

C7 R7

C4 Partnership Working Amber R4 Audit Committee Regular

Jan 18

April 18

Vacancy rate higher than target and high level of Reliance on Agency Staff to cover vacancies

July 2017Nov 17April 18

Jan 18

April 18Amber

Monthly Green

G5

Programme management approach to the ownership, monitoring and management of CIPs through the PMO, supported by a revised CIP, QIPP, Partnership (CQP) Board

Green R3 Finance and Performance Committee

Green

Reserves / Provisions to offset financial risk Amber R2 Management Executive Team Meetings Monthly

Annual Financial Plan including budget monitoring and management Green R1 Quarterly Performance Reviews

Apr-18The risks are CONTROLLED by… Strength The REPORTING mechanisms are…


AmberGreen

Size of the Trust and place in the local health economy / regional health economy

GAP ACTION PLANFinancxial Modelling and Sustainability identified in the TCT Full Business Case

G1 Under delivery of the CIP Schemes Identify mitigation plans against high risk schemes and full review of forecast outturn

The GAPS IN CONTROL / NEGATIVE ASSURANCES are…National context - Proposed financial settlement from 2017/18



ORIGIN

Trust Board

Well Led Domain PC4Agreement that CCG not levy fines until service model reviews particularly IAPT have been reviewed MExT

CQUIN Progress Report Q&S Committee


What are the key potential consequences (up to 4) of the risk? Annual internal audit of the CIP Process Audit Committee

PC1 Loss of organisational control

Ad hoc reporting to F&P and Board Finance & Performance Cttee / Board

PC3Inability to maintain safe and effective local services

Monthly Returns to NHS Improvement NHS Improvement Portal

Financial System Audit - internal audit plan approved Audit Committee


Managemant and Committee Reports monthly - Strong cash position Finance & Performance Committee / MExT / Board

PC2 Negative financial impact on local health economyDevelopment of Financial information for partnerships and STP Board Development

Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CREWS domains Contracts with two main Commissioners signed


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) @ 16/2 Red: 5 x 4 = 20CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Red: 4 x 4 = 16What is the strategic risk to be controlled?

STRATEGIC RISK EXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?

Trend in Assured

Level

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK

SR 2 Financial Sustainability Director of Finance Finance & Performance Committee Red

POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / Meeting

Audit CommitteeYear end Audit process - sign off of accounts and audit letter giving good assurance on some of the key financial systemsA1


REFQ1 REFQ2

Q2/Q3 A1Q3 A2

Q4 A3

REF A4A5A6

A7

A8A9

A12A13A14 Trust BoardA15 Quality & Safety CommitteeA16 Trust Board

REF RAG A17O1 Recruitment of Clinical Staff Red A18O2 Higher turnover of Staff Red A18O3 Working torwards the national Agency Staffing Cap AmberO4 Clinical Supervision RedO5 Small Bank service AmberO6 Continuous need to deliver Cost Improvements RedO7 Increasing emphasis on working with our Partners AmberO8 CQC Inspection outcome and recommendations Red REF DEADLINEO9 West Midlands Quality Review Outcomes Red

O10 Patient Experience Feedback AmberO11 Amber


IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Quality and Safety Cttee Chairs reportQuality and Safety Reports to Quality & Safety Committee and Trust Board Q&S Committee / Trust Board

STRATEGIC RISKEVIDENCE

What is the report received that provided that assurance? Board / Committee / MeetingQuality Account presented and approved by Trust Board Trust Board

SR 3 Achieving quality of careDirector of Nursing and

OperationsJoint Medical Director

Quality & Safety Committee AmberPOSITIVE ASSURANCE

Annual Report on Infection, Prevention and Control Trust Board

Trend in Assured

Level


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) Red: 5 x 4 = 20 CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Amber: 4 x 2 = 8What is the strategic risk to be controlled?

EXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?


PC2 Not a provider of choice and negative impact on likelihood of GPs promoting the Trust

Patients health and well being at risk Reduction in patient referrals and related income

PC3 Increase in patient complaints and poor patient experience with a poor net promoter scoreIMPACT ON CQC CREWS domains

Transform Services to improve the Patient Experience and Quality of Services

What are the key potential consequences (up to 4) of the risk?

PC1

AllDomains PC4 Non compliance with our regulatory requirements and commissioner contracts, potentially resulting in greater external regulation no longer being able to Safer Staffing Report

Royal College of Pschiatrists Centre for Quality Improvement (CCQI) Accreditations (Reported through the Quality Account)A10 Trust Board

CQC Good Inspection Report Trust Board

Trust BoardNursing Strategy Trust Board


Medical Directors Report to Board / Nursing Director report to BoardAnnual Report on Research and DevelopmentStaff Survey Results What are the most significant origins hich could or have led to the risk?


GAP ACTION PLAN

ORIGIN Staff Friends and Family Results Trust Board

The GAPS IN CONTROL / NEGATIVE ASSURANCES are…

Jul-18

May-18

Whistleblowing Policy approved and quaretly freedom to speak up Report Trust Board

The risks are CONTROLLED by… Strength The REPORTING mechanisms are… Strength

G1 Delivery of the Priority Activities 201718 Action Plan with Quarterly Milestones agreeed and Monitored Quarterly

G2 Delivery of the Quality Priorities and CQUIN's Implement Actions to deliver quality Priorities and CQUIN's in 2017/18

G3

Lack of capacity appropriately skilled managers and clinicians


Green

What are the key controls that are in place to mitigate these risks?Red

AmberGreen

What are the key reporting mechanisms that will provide assurances that the key controls are effective? (E) = External assurance.

RedAmberGreen

C1 Agreement of Priority Activities in the Annual Plan 2016-17 Green R1 Quality & Safety Committee Monthly

C2 Quality Impact Assessment carried out for all CIP schemes Green R2Sub Committees and groups reporting to Quality & Safety Committee

Monthly

Green

Green

Monthly GreenC3 Quality Improvement Strategy & Quality Priorities for 2016/17 Green R3 Trust Board

C4

C6 OnBoard Walkabouts Amber R6

C5 Process in place for staff to raise concerns and whistleblow that are regularly reviewed Amber R5 Quartely Performance Reviews GreenQuarterly

6 weekly Green

CQC Action Plan Green R4 Finance & Performance Committee Monthly G9

C7 Nurse Revalidation Green R7

C10 Clinical Audit Green R10

Medical Revalidation Green R9

C8 Experts by Experience Visit Feedback and Reviews

C11 Service Development Quality Impact Assessmment Green R11

Green R8

Annual Green

CLRN - Clinical Research Network Midlands (e) Monthly

C13

C9 Internal Audit reports (e) Ad hoc Green

CCG CQRM meetings (e) Bi Monthly Green

6 monthly

6 monthly

Green

Green

Green

GMC PEST training survey feedback (e) West Midland Deanery Feedback on Foundation Training schemes (e)

Mortality Review Group

Essential skills training clinical role specific Health Education England - Workforce Return (e)

CQC reports and visits (e)

R15

R16

CQC Meetings & Progress Updates (e)

Monthly / Quarterley Green

Three Monthly IDM (e) Quarterly Green

Ad hoc Green

External stakeholder visits (e) Ad hoc Green

R12

C14 Postgraduate training scheme under West Midlands School of Psychiatry with training placements for junior medical staff

Green R14

C12 Research and Development Amber

R13Green

Research and Development Review work that had already been undertaken to channal R&D through TCT partners Mar-18

Nov 17Mar 18

Quality Improvement Strategy not fully implemented Implement the Quality Improvement Strategy in accordance with plans by achieving 2017/18 deliverables and milestones May-18

Rolling out availability of esential skills trainig to all front facing clinalposts

Profiling of staff and breaking down of clinical and essential skills in the next stage of the roll out. Profiling for Medical workforce oustanding after which the revised matrix will be built into the Mandatory Training Policy

Combining Statutory / Mandatory and Essential training into individual plans for staff members / groups of staff

CQC Action Plan Approved and update reports to Quality & Safety Committee Trust Board / Quality & Safety CtteeQ&S CommitteeQuality Priorities 2016/17 completed and 2017/8 approved and on target

Quality & Safety CommitteeClinical Audit PlanTrust BoardAnnual Medical Revalidation Report to Board Nurse Revalidation Report

Board DevelopmentCIP POD (includes QIA)

Trust Board / Quality & Safety CtteeQuality Improvement Strategy 2016/2020 approved and annual milestones delivered

G8 Safer Staffing Assurance

Implement Protocol agreed at Board in November 2017 and embed as part of quality assurance monitoring

Jul-18

G5 CQC Inspection Report - Recommendations Implemention of the CQC Action PlanJul 17Nov 17Mar 18

G6 CQC Inspection Report - trajectory to outstanding Develop Plan of actions required to move the Trust to outstanding

G7 On Board WalksJuly 17Nov 17Apr 18

G4

Nurse Establishment Review and Policy ReviewWork done to harmonmise the approach with the Trust's TCT partners and Trust Policy requires review

Sept 17Nov 17Jan 18


REFQ1 REFQ2

Q2/Q3 A1Q3 A2Q4 A3

REF A4A5A6

A7

A8A9

A10A11A12A13A14A15A16A17A18

REF RAG A19O1 Red A20O2 AmberO3 GreenO4 RedO5 RedO6O7 REF DEADLINEO8O9

O10


IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Implementation of Staff Engagement Programme / Report to Board Trust Board

STRATEGIC RISKEVIDENCE

What is the report received that provided that assurance? Board / Committee / MeetingRegular workforce report to Trust Board Trust Board

SR 4 Ability to recruit and retain staff Director of People and Corporate Development Workforce Committee Red

POSITIVE ASSURANCE

Regular workforce report to Finance & Performance Committee Finance & Performance Committee


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) Red: 5 x 4 = 20CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Red 4 x 4 = 16What is the strategic risk to be controlled?

Trend in Assured

LevelEXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?


CQC Report Trust Board

PC2 Increased use of agency staff with negative impact on quality and cost of care including lack of continuity of care

Internal Audit Report on Staff Engagement Audit Committee

Develop the organisational culture and capabilities to support high quality service delivery

Delivery of poor care (with potential high incidents and complaints)

Quality Report (reporting of incidents) Trust Board

PC3 Impact on capability to deliver activity to contractService Experience Reports Trust Board

Safer Staffing Report Trust Board

IMPACT ON CQC CREWS domains Use of Temporary Labour monitoring report Finance & Performance Committee


What are the key potential consequences (up to 4) of the risk? Outcome of Staf Survey Results Trust Board

PC1

Caring Responsive and Safe Domains PC4Negative impact of remaining staff on job satisfaction and morale

TCT Partnership Vacancy Control Process Workforce CommitteeInternal Audit Report of Recruitment System

Lack of suitable candidates

Audit and Workforce CommitteesCompleted Vacancy Review Workforce Committee


Internal Review of last 10 recruitments Executive DirectorsKPI's for Recruitment Process agreed and progress against monitored Workforce Committee


AmberGreen

ORIGIN

Competition from other local and larger TrustsCarrying larger than target vacancy rate The GAPS IN CONTROL / NEGATIVE ASSURANCES are…Staff morale, motivation and resilience in an ever changing environment National Shortage of staff in certain disciplines


GAP ACTION PLAN

The risks are CONTROLLED by… Strength The REPORTING mechanisms are… Strength

G1 Effectivess of Recruitment ProcessFollowing positive evaluation of Recruitment System embed this in the Trust Recruitment Policy, extend trainig on the system and develop internal KPI's

Dec 17

March 18

Dec 17

March 18


Green


RedAmberGreen


RedAmberGreen

C1 Recruitment plans in place for all higher risk areas Amber R1 Trust Board Monthly

C2 Close liaison with the University Green R2 Workforce Committee Monthly

Use of locum Doctors, agency (locum process to be agreed - October 2017)

Dec 17Green

Green

Monthly Green

Annually Recruitment to Junior Doctor VacanciesRecruitment through the Deanery and of Middle Grade Doctors

Review posts that were being held vacant and prepare to recruit to as appropriate

Jan 18Feb 18

Retention of Staff as a result of the TCT Integration Process (particularly in corporate areas)G2

C3 Leadership Development Programme Amber R3 Staff Partnership Panel

Key posts to be identified and individual solution to be developed and progressed through the usual vacancy control process

C4 Staff Engagement Programme and Staff Survey Action Plan Green R4 Staff survey (e)

C6 Recruitment Process Amber R6

C5 Use of temporary Labour (Monitoring Process) Green R5 Internal audit reports (e) Green Data collection and analysis of the impact of the difficulties in recruiting

Dec 17Ad Hoc

G4

G3

Locum Agency Protocol / Proforma Amber R8

C7 Workforce Development Plan Amber R7

C9 R9

C8

C10 R10G6

G5


REFQ1 REFQ2

Q2-Q3 A1

Q3 A2

Q4 A3REF A4

A5A6A7

A8

A9

A10

A11A12

PC5 A13

A14

A15A16A17A18

REF RAG A19

O1 Amber A20

O2 AmberO3 AmberO4 Red O5 AmberO6 RedO7 Amber REF DEADLINEO8 AmberO9

O10


Health & Safety Executive Visit and Report on the Trust's management of the water supply


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 4 x 5 = 20CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4 x 4 = 16What is the strategic risk to be controlled?

Trend in Assured

Level

Independent Engineer for Water Management Presentation to Board - Assurance around the implications of the water management issues Trust Board

EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence

be located?

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Annual Report from Independent Engineer Quality &Safety Committee

STRATEGIC RISK

SR 5Management, Maintenance and Strategy for the Estate

Director of Nursing, Operations and Estates Quality & Safety Committee Red

POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / MeetingPLACE Survey outcomes and action plan approved MExT / Capital Planning


What are the key potential consequences ( of the risk? Independent Risk Assessments Water Management Group

PC1 Impact on the quality and safety of the care that the Trust is able to provide its patients

Trust Board

PC3 Failure meet specific needs of Trust's client GroupTrust Board

DON's report to Board Trust BoardEstates Compliance Matrix Quality &Safety Committee

PC2Potential restriction on the services the Trust could deliver and it capacity resulting in failing to comply with its contractual obligations with Commissioners

Estates Gap analysis completed Quality &Safety Committee

IMPACT ON CQC CREWS domains Infection Prevention and Control Sub Committee Exeception Report and risk report the normalisation of water monitoring in the Trust Quality & Safety Committee

Bushey Fields Refurbishment Plan approved

Safe, Effectiveness Domain PC4 Failure achieve outcome 6 facests surveyEstates Plan Trust BoardOverarching Fire Safety Action Plan Quality & Safety CommitteeAd hoc responses to reporting requests from regulatory bodies - including NHSI, H&SE, Public Health England Estates TeamFailure to comply with legal compoants Fire, water electricity and health and

safety


Business Cases supporting capital investments to Estates and Capital Planning Group Estates and Capital Planning Group

ORIGINRecommendations from Previous Independent Reports on the trust's Estate not being acted upon through changing priorities and demands on personal


AmberGreen

Lack of front-line staffing within the department GAP ACTION PLANCompletion of PAM in autumn 2017 has identified a wide range of improvements required

G1 Impact of implementation of the Estates Plan Monitor delivery through the Estates and Capital Planning Sub Committee

The Development of a Strategic estates risk register in June 2017

Limitations of Bloxwich Hospital for our client group served

The GAPS IN CONTROL / NEGATIVE ASSURANCES are…Fire safety risk issues identified in the course of 2016/17 and the subsequent development of the Fire Safety Risk Group

What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?Gaps in strategic and operational management

Water Management Issues initially identified in 2015/16 ongoing across all hospital sites

Strength


RedAmberGreen


RedAmberGreen

G3

Sept 17Nov 17

April 2018

G2

The Trust is not fully aware of the condition and utilization of the Trust's estate (Cross ref to Strategic Estates RR C&E 02, 03, & 05; also C&E 04 in relation to NHS Property Services)

Six Facet Survey commissioned to be undertaken Dec 17Mar 18The risks are CONTROLLED by… Strength The REPORTING mechanisms are…

The Trust cannot provide evidence that it is compliant with best estates practice as laid down in the NHS Premises Assurance Model (PAM)

Investment has been agreed to release resource to implement and evidence the PAM across the Trust

Sept 17Dec 17June18


G4 Specific areas of non-compliance with PAM - Electrical Safety across all Trust sites (non-HV)

Develop action plan around developing accurate drawings and schematics to aid understating of system connections. Any urgent matters would be referred to the Estates helpdesk

Sept 17Dec 17Mar 18Green

C2 PLACE Survey R2 Finance & Performance Committee Monthly

C1 Estates Plan Red R1 Trust Board Monthly

Green

Specific areas of non-compliance with PAM - Gas Safety across the Trust

Policy, procedure and documentation to be standardizedAudit of Gas safety certificate to ensure complianceAny urgent matters would be referred to the Estates helpdesk

Sept 17Dec 17Mar 18Green

Green

G5 Speciific areas of non-compliance with PAM -Ventilation Systems and the management of ventilation systems

Authroising Engineer to be appointedA full appraisal of assets is to be completed (December 2017)Policy to be written along with procedural guidance (December 2017). Any urgent matters would be referred to the Estates helpdesk

Sept 17Dec 17Mar 18

C4 Approved Business Case Process R4 Fire Safety Working Group Bi-Weekly

Monthly Green

G6

C3 Capital Programme overseen by Estates and Capital Planning R3 Estates and Capital Planning

GroupGreen

Green

C6 Independent Risk Assessments for 3 hospital sites Green R6 ERIC Returns published through HSCIC website (e)

C5 Annual Ligature Assessment Review R5

Stakeholder Conference Calls / Meetings with exteral stakeholds inc HSE and Public Health England (e)

Green

Annual Amber

G8 Facilities Management Impact assessment of the pause in intergration on the procurement of the facilities management contract Jan-18

Green

GreenG7 Leadership and Capacity Secure additional strategic and management operational

support for the estates function Feb-18Ad Hoc

C8 Implementation of Fire Safety Action Plan Green R8 CQRM's (e) (Bi) -Monthly

C7 Appointment of relelvant authorized persons Green R7 Three Monthly IDM (e) Quarterly

GreenG9 Management SLA with BCHC not yet signed SLA to be agreed between DoF and BCHC's Director of

Estates Feb-18

C10 The Premises Assurance Framework Amber R10G10

C9 Development of a management SLA with BCHC Amber R9

REFQ1 NEW REFQ2

Q2/Q3 A1Q3 A2Q4 A3

REF A4A5A6

A7

A8A9

A10A11A12A13A14A15A16A17A18

REF RAG A19O1 Red A20O2 RedO3 AmberO4 Amber

O5 AmberO6 RedO7 REF DEADLINEO8O9O10


C8 TCT Budget Allocated Amber R8

C7 Backfill Arrangements Green R7

C10 Moving Forward Plan Amber R10

C9 TCT Governance and project structure following NHS Improvement Guidance Green R9

G10

G9

Monthly Green

G8

GreenG7

Monthly

C6 Quality Assurance Mechanisms Green R6 3 Way Executive Management Forum

C5 Incident Reporting systems and processes Green R5 TCT Intergration Board

C4 Organisational Change Programme and TUPE Consultation Green R4 TCT Sponsors Group Monthly

Monthly Green

G6

C3 Internal Communications and TCT Listenting Events Green R3 Finance & Performance Committee

Green

GreenG5

CONTROL REPORTING MECHANISMG4

Clarity on the Clinical Leadership and Clinical Governance Model supporting Board to Ward visibility proposed for the enlarged organisation.

Meeting Arranged between the Executive Directors of the Trust and BCHC, supported by a discussion paper on 2 October 2017

Nov-17Green

C2 Staff Health & Wellbring Plan Green R2 Quality & Safety Committee Monthly

C1 Agreed Vacancy Control Process Green R1 Board Monthly

Strength


RedAmberGreen


RedAmberGreen

G3

Aug-17Dec-17

G2Identify the risks to the Trust as a result of the delay in the Transaction and develop mitigations plans as necessary - Agree the Business Continuity Plans across the Trust

Dec 18

Mar 18The risks are CONTROLLED by… Strength The REPORTING mechanisms are…

Agree and Deliver the TCT 'Moving Forward' Plan Jul-18

Further Pause in the TCT Integration Date

GAP ACTION PLAN

G1 Agreement of TCT costs across the three Trusts Discuss and Agree costs

Non-Compliance with technical aspects of organisational change through TCTIncreased emphasis on working on the TCT Agenda impacts on the quality and safety of service delivery The GAPS IN CONTROL / GAPS IN ASSURANCES are…Financial impact of TCT becomes unmanageable Lack of a contingency plan should the Full Business Case not be approved by either of the Council of Governors of the FT's, NHS Improvement or the Secretary of State ns the Trust What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?Continuity of Leadership and knowledge of Mental Health Services

Tranisition through TCT results in staff feeling disengaged , increased sickness levels and increased turnover


AmberGreen


ORIGIN

MExTAll Domains PC4

Inability to maintain safe and effective local servicesNumber of Trust staff nominated onto BCHC Leadership Development Programme Executive Director MeetingAppointmrent of BCHC Chief Executive and involvement in the process Board


What are the key potential consequences (up to 4) of the risk? Approved Heads of Terms Board

PC1 Delivery of poor care (with potential high incidents and complaints)

Communications and Engagement Plan Integration Board

PC3 Impact on capability to deliver activity to contractTCT Organsational Development Plan Integration Board

TCT Governance Structure Board


Progress Reports from the Integration Board Board

PC2 Increased use of agency staff with negative impact on quality and cost of care including lack of continuity of care

HR suuport to manage the tranisitional arrangements MExT

Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CORE OUTCOMES Backfill Arrangements Agreed

Vacancy Control Process MExT

EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the

evidence be located?

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Quality Assurance and Performance Reports to Board and Committtees Board & Committee Meetings

Trend in Assured

LevelSTRATEGIC RISK

SR6 TCT Integration Chief Executive Board RedPOSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / MeetingFull Business Case Board


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 4*4= 16CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4*4 = 16What is the strategic risk to be controlled?


Agenda Item number:10.1

Enclosure: 24

Report Title:

Communications & Engagement Quarterly Dashboard – Quarter 3


Mark Axcell, Chief Executive Officer


Michelle Carr, Communications and Engagement Manager

Purpose of the report: To update the Board on communications and engagement

activity.


Decision / Approval

Gain assurance

Discussion

Information


Committee: MExT

Date reviewed: 23 January 2018


Report received for assurance


services


Leadership culture






Caring The report provides information on how the Trust plans to engage and communicate with stakeholders and build strong relationships that will support its role as a responsive, effective and well-led organisation. It describes progress against our plans to develop the tools and target the messages that are appropriate for our diverse stakeholder groups.


Enc 24 Trust Board Communications report Q3 17 18 Final Page 1 of 6

Title Communications & Engagement Quarterly Dashboard –

Quarter 3 Introduction This is the quarterly communications and engagement report that updates progress against the Communications and Engagement Strategy 2015 -19. Summary of key points, issues and risks Strategic partnership communications - TCT

This quarter we have continued to develop the TCT blog – a newsletter that updates staff on how plans for the TCT partnership are developing. We’ve also contributed to questions raised by staff and are currently in the process of updating the Q&As. Central to the success of TCT is strengthening how we work together. As a communications function we meet on a regular basis and we are starting to share our experiences to shape work. For example, we are currently looking at how BCHC positioned communications on the work that took place with Newton Europe, a company that we are soon to working with to explore how we might improve processes in some of our front line services. We are also trying to highlight how we are working together not just in communications but across other areas of service such as joint bidding and sharing and harmonising policies. Winter communications We have contributed to the local winter communications plans which is a requirement for all STPs to produce. Working with local NHS organisations we have collectively developed plan of key messages and promotion to staff, patients and the public, supported by national materials provided by NHS England. Part of the winter campaign is encouraging staff to take up the flu vaccination. This year we have looked across local health partners to share best practice and are ensuring a regular programme of communications for staff. During the bad weather that we experienced late last year, we recognised that on occasion, there might be a need for on-call communications support when urgent messages are needed for staff / patients. We are developing some options to share on-call communications support across the Black Country. Supporting service changes Over the past few months we have provided communications and engagement support for a number of service changes. In November / December we ran an engagement process around


the proposals to re-locate certain services currently delivered at Bloxwich Hospital, asking patients, carers and staff for their views. Feedback has been given to the project lead and was incorporated into a presentation for Walsall OSC in January. We have also supported communications and engagement around the closure of Birch Day Hospital and have worked with the service to draft letters to patients and family members along with internal communication to staff about the closure. We will be informing stakeholders shortly. GP Portal We have started to develop a dedicated area on our website for GPs and referrers providing clear, up to date information on how they can refer to services and feedback. The next phase of this will be to test the pages with some GP colleagues from Dudley and Walsall, we are working with CCG communications colleagues to support this. Thrive Mental Health Commission Awards We recently received confirmation that two of our entries to the West Midlands Thrive Mental Health Commission Awards have been shortlisted. The awards aim to recognise mental health stars in the West Midlands Combined Authority area and Kelly Plant, Clinical Inpatient Manager at Bushey Fields Hospital and David Stocks, one of our EBEs have been shortlisted. Andy Williams, one of our other EBEs has also been shortlisted for an award following an external nomination. The ceremony takes place on 31 January at West Bromwich Albion Football Club. Street Triage Filming At the beginning of January the Black Country Street Triage team took part in filming as part of BBC One’s Ambulance series. The production company followed the team for four days as part of the documentary. Feedback on the filming has been positive and we are hopeful that it will be included in the final edits. Any footage used will be seen first by us to support the editing process. The programme is due to air in the Spring and we will share the date with you as soon as we are able to. In Quarter 4, 2017/18 we will be focusing on:

• Marketing our Talking Therapies service to increase referrals in both teams including a campaign to encourage NHS staff to train as PWP workers

• Supporting the THRIVE contract mobilization – following our successful bid, the team are preparing press releases and a marketing plan to support referrals to this new service.

• Time to Talk celebrations – supporting the national Time to Talk campaign on 1 February and using it as an opportunity to promote local mental health services. Our Mental Health Forum will also run on 1 February and will be on the subject of Personality Disorder.


• Prepare materials to support the launch of smoke free across the Trust. We have approached other Trust’s to see what has worked well for them

• As the MCP progresses we will be looking at increased engagement with staff • Publishing the next edition of One in 4 membership magazine

Further detail (if required) Press coverage report and communications dashboard is appended. Recommendation The Board is asked to receive the report and further appendices for information and discussion. Board action required There are no actions for Board.


Communications and Engagement Dashboard Quarter 3, 2017/18

Press coverage Quarter 3, 2017/18

Top 3 page hits quarter 3 Website

Enhanced Primary Care Dudley (5,046) Contact us (4,256) Mindfulness Meditation Audio Tracks (3,472)

The Exchange Phonebook (45,058) Oasis (31,397) ESR (10,098)

Top 3 downloads quarter 3 Website

Seven-Eyed Model (4,317) LD CAMHS P28 (1,697) Work Experience and Shadowing Application Form (1,554)

The Exchange

TCT FAQ (729) Sickness Absence Policy (248) Payroll Cut Off Dates (175)

Activity Q1 Q2 Q3 Q4 Press releases 4 3 4 Press coverage 30 N/A 52 Media enquiries 2 1 3 Twitter followers 1,503 1,593 1,658 WellMind downloads

38,750 48,299 51,047

WellMind rating (app store)

N/A 3.2 3.2

New members 4 2 1 Lost members 6 19 14 Total public members

7427 7410 7395

Oct-17 Nov-17 Dec-17 Press releases 1 1 2 Press coverage 17 7 19

Value £7793.79 £6533.38 £12522.99 Reach 317,533 178,096 380,998


Membership total

£0.00

£2,000.00

£4,000.00

£6,000.00

£8,000.00

£10,000.00

£12,000.00

£14,000.00

Apr May Jun Jul Aug Sep Oct Nov Dec

Equi

vale

nt a

dver

tisin

g va

lue

Value over time

7427 7410 7395

0

1000

2000

3000

4000

5000

6000

7000

8000

Q1 Q2 Q3 Q4

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Apr May Jun Jul Aug Sep Oct Nov Dec

New

spap

er re

ach

Reach over time




Enclosure: 25

Report Title: MERIT Vanguard Overview Report – Quarter 3 Accountable Director:

Mark Axcell – Chief Executive


Mark Axcell – Chief Executive

Purpose of the report: The attached updates the Board on progress with the MERIT

Vanguard. Action required from the Board Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


The Board is asked to note progress with the MERIT Vanguard.


services


Leadership culture






Caring

The MERIT Vanguard aims effect all CQC domains


Enc 25 MERIT Vanguard Overview Report Page 1 of 16

Title MERIT Vanguard Overview Report – Quarter 3 Introduction MERIT alliance is an equal partnership between four trusts:

• Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) • Black Country Partnership NHS Foundation Trust (BCPFT) • Coventry and Warwickshire Partnership NHS Trust (CWPT) • Dudley and Walsall Mental Health Partnership NHS Trust (DWMHT)

The programme consists of two clinical workstreams (Crisis Care; and Recovery Culture) and five enabling workstreams (Information Technology; Workforce; Quality Governance; Equality & Diversity; and Research & Innovation). The report outlines the main achievements in the reporting period and that planned for the next along with the key risks and issues in the workstreams and their mitigations. Summary of key points, issues and risks The appended report provides progress with, and the impact of, the MERIT Vanguard programme against the targets which MERIT set itself to achieve. It goes on to discuss what is needed, going forward, to ensure that this work is continued to enable it to achieve its maximum impact. Section 2 provides an evaluation of the current achievements to date and the associated impact. A detailed evaluation report will also be produced and shared with Trust Boards in March 2018 reviewing the overall programme during the NHSE funding period. Section 3 outlines the agreed areas of work, approach and next steps into 2018/19. Further Information The progress and next steps report presented to the Boards of the 4 partner organisations is appended to this report. Recommendation That the board receive this quarterly update on progress with the MERIT vanguard Board action required To receive the report for assurance and support the next steps.

Enc 25 MERIT Vanguard Overview Report

MERIT progress and next steps report to Trust Boards

January 2018

1.1 Purpose

The purpose of this report is to provide progress with, and impact of, the MERIT Vanguard programme against the targets which MERIT set itself to achieve. It goes on to discuss what is needed, going forward, to ensure that this work is continued to enable it to achieve its maximum impact. Section 2 provides an evaluation of the current achievements to date and the associated impact. A detailed evaluation report will also be produced and shared with Trust Boards in March 2018 reviewing the overall programme during the NHSE funding period.

1.2 Key Achievements

MERIT has delivered some significant achievements over the last 2 years which is outlined in section 2. Some of the key achievements are listed below:

• The development and launch of the initial phase of Crisis Care Website • The development and introduction of the Electronic Shared Health Record Viewer allowing clinicians to see patient demographic information

from a neighbouring MERIT Trust • The establishment of a coordinated bed management function across the MERIT Trusts supported by an electronic bed viewer • Development of recovery practices with the use of Re-focus and Requol • Delivery of Mental Health First Aid training • Establishment of training passport across MERIT Trusts • Joint recruitment activity, shared training and temporary staffing alignment • Establishment of time to shine toolkit providing collaborative support and mock inspections across MERIT Trusts


1.3 Recommendation

It is recommended the Board agree the five priority areas for MERIT in 18/19 identified by the MERIT Steering Group outlined in section 3.1, the benefits set out in section 3.2 and approach set out in section 3.3.

2.1 Evaluation Introduction

An independent organisation (Mental Health Strategies) is undertaking a detailed evaluation throughout the period of the two-year programme. They have so far produced three detailed, formative evaluation reports based on both quantitative (analysis of data and metrics) and qualitative (based on interviews) feedback. The detailed reports have been presented to the MERIT steering group and to each Trust Board, as well as to the Merit workstreams, and are available separately. A final report for the Vanguard and for NHS England will be produced at the end of March 2018. This report is based on findings from their reports.

Table detailing progress against key MERIT targets and what is needed to enable this work to progress to achieve its full potential

Key target Achievement to date Work planned/needed after the end of the MERIT programme to develop to full potential

RECOVERY CULTURE AND COMMUNITY CONNECTIONS WORKSTREAM 1 Develop an

evidence based recovery model

An evidence based model for Recovery has been developed, based on a systematic review of robust, research based evidence. This clearly identifies those interventions which have been proved to have a positive impact on a person’s recovery from mental ill health. A programme of recovery focused work has been developed, building on this model. This includes the use of Requol (a quality of life tool) and Re-Focus (an evidence based approach which staff use to inform their practice). In addition work has begun to give staff across the four trusts, specific skills in implementing change, as this is a complex skill set needed to ensure that this work fully embedded and sustained. It can also

Full implementation of an evidence based recovery model across all four trusts has the potential to lead to improvements in a number of key indicators including to reduce admission rates, increase patient and carer satisfaction and experience and increase service user quality of life. By March 2018 the ground work to enable this to happen and move to the next level will be complete. This was originally envisaged as a three year programme of work in order to deliver its full potential impact. Substantial momentum has been achieved which, with continued support, should enable delivery of


Key target Achievement to date Work planned/needed after the end of the MERIT

programme to develop to full potential support other service improvement initiatives. The above programme has started with staff training and pilot work undertaken in each trust. A number of recovery focused events have been held for staff, service users and carers which have been very well received. A number of funding models have been agreed and a number of bids for funding have been developed. Recently received £25k from Health Education England to deliver change agent training.

this ambitious programme. The trusts are well placed to build on this momentum in a variety of ways for example to:

• Use the Re-Focus skills gained to further develop Recovery Culture across all Trusts (supported by change agents).

• Put in place processes (including clinical documentation and working practices) to support the full implementation of Requol.

• Continue to engage service users and carers in this work at scale

• Continue to work with wider partners to ensure work is in synergy and use available resources most effectively

• Continue to use the evidence based model to direct recovery focused work.

2 Increase community support available to patients and carers leading to fewer crisis episodes

Mental Health First Aid (MHFA) training was identified as the most effective tool to achieve this target. Eleven new instructors have been trained across MERIT to add to those already working in Birmingham and Solihull MHFT. The Alliance is working with key stakeholders across the West Midlands (including West Midlands Combined Authority Mental Health Commission) and third sector organisations) to identify the most effective way to roll this out at scale. There is 14 staff trained in Mental Health Frist Aid. To date the total number of people receiving MHFA training during Q1 and Q2 for 2017/18 was 122 to 101 respectively.

The Alliance needs to agree and implement a strategy to roll this out at scale in order to be most effective at community level. All of the ground work has been done to enable this to happen and move to the next level. Potential to develop an income generating function for MHFA.



programme to develop to full potential Local evaluation is ongoing to capture the impact of this training.

3 Improve patient and carer experience

The Friends and Family (FFT) test scores have risen steadily throughout the period of the MERIT programme at all four trusts and for MERIT overall from a baseline of 81.8% to 85.9% in the latest quarter. Whilst the sustained improvement in the numbers of service users responding positively to the FFT cannot be attributed directly to this programme, it is positive that, during the period that the programme has been in place, the overall FFT scores have increased steadily across the MERIT trusts. Through MERIT, service users and carers have been involved in the development of a number of initiatives and large numbers have attended specific events and contributed their ideas, skills and experiences in order to benefit services. Good practice has been shared across the trusts. For example experts by experience (EBE) at Dudley and Walsall FT have designed an EBE training package which is being shared across the Vanguard. EBEs who have been involved in the MERIT programme have been very positive. They feel that the areas it is focusing on are important, relevant and needed, that their views, skills and contributions are valued, and reported that being involved had had a positive effect on their own personal mental health. Senior executives have recognised the EBE contribution as having been significant and valued their passion and insight.

There are many advantages to building on the enthusiasm and commitment of service users, experts by experience and carers and ensure that this continues to be harnessed. The MERIT programme should be able to have a really positive legacy in this way across all of the organisations involved., benefitting both the organisations and the individuals involved. For example, continuing to deliver events which are shared across the four organisations and sharing the EBE training are just two ways in which this work could continue to have impact. It would also be helpful to continue to monitor the impact on patients and carers through FFT and other methods of feedback.



programme to develop to full potential One service user said

“...staff try really hard but at the end of the day service users can think about things that staff will never think about....”

CRISIS CARE WORKSTREAM 4 Implement a

single bed management function with streamlined, clear and efficient processes to maximise and increase flexibility of our bed utilisation

All trusts are fully signed up to the implementation of a coordinated approach to bed management, underpinned by clear operating instructions and memorandum of understanding. The bed managers coordinated function went live in mid-December 2017 through a weekly conference calls and other regular communication. Since the MoU and standard operating procedures have been in place 13 patients have been placed in MERIT Beds in Q2/Q3 avoiding out of area placements. This is an increase from previous two quarters which totalled 4 placements in MERIT Beds. As the process is refined and embedded it is anticipated the numbers will increase, as patients from one MERIT trust are treated in another Trust bed in preference to being sent completely out of area. Bed occupancy levels continue to be high across all Trusts following the national trend, particularly for Acute Adult beds with an average of 100% across MERIT. Older Adult beds bed occupancy levels vary more between trusts ranging from 74% to 100%.

Everything is in place for this to continue to operate effectively across all MERIT trusts. As it is still early days, the impact will need to be closely monitored and any necessary changes agreed and implemented. This will require development of the bed management process, ongoing good working relationship between the Trusts at both operational and corporate level with programme support. Pilot Electronic Bed Viewer requires further development and refinement. As a next step Forward Thinking Birmingham (FTB) will be integrated into the bed management function and viewer.



programme to develop to full potential 5 Reduce number

of patients being treated out of the MERIT area (for non-specialist inpatient care)

See above. With the implementation of the above, the number of patients treated out of area will reduce. Levels were historically high particularly for Coventry and Warwickshire Partnership Trust and Birmingham and Solihull Mental Health FT, however they have begun to come down. Dudley and Walsall Mental HealthTrust does not currently send patients out of area for non-specialist care.

We continue to hear harrowing stories from carers of patients sent far from home for treatment at a time when they are acutely unwell, and recognise that the distress caused by this is significant. This emphasises the need to continue with this initiative. Early work with the bed managers working together has already shown opportunity to reduce out of area and better coordination and appropriate repatriation.

6 Reduce length of stay

This is being monitored, but as yet, the work has not impacted on this measure.

Closer co-operation between the four trusts would enable more detailed review and sharing of good practice between trusts, to ensure lengths of stay are not prolonged unnecessarily.

7 Reduce admission rates

Admission rates remain high, as demonstrated by consistently high bed occupancy rates across the Vanguard and high levels of out of area treatment, particularly for the two biggest MERIT trusts.

This demonstrates the continued need for the MERIT programme to continue.

8 Increase access to services (within and “out of hours”) across geographical boundaries

At present little work has been undertaken to change clinical services and impact on these outcomes, although the crisis care website (see comments above) has the potential to increase access by increasing the amount of information available to service users and their families, regarding what services they can use when dealing with a rapid deterioration in their mental health. It was initially envisaged that work to do this would take place in year three. It was also envisaged that the “seven day working” workstream (which was stood down due to reduction in central funding) would impact here.

There is considerable potential to build on the excellent working relationships which have developed across the four MERIT trusts and on the programme of work already established, to further impact in this area.



programme to develop to full potential 9 Reduce

attendances at A&E for patients in mental health crisis.

Attendances at the MERIT A&E departments for people with a psychiatric disorder have continued to rise in recent years. At present little work has been undertaken which might impact on reducing attendances at A&E, although the crisis care website (see comments above) has the potential to do so.

There is considerable potential to build on the excellent working relationships which have developed across the four MERIT trusts and on the programme of work already established, to further impact in this area. Much of this work is interlinked, eg work to increase access to services out of hours (8) and to Increase the number of patients engaging with mental health services earlier in their illness, ie before crisis point should all ultimately impact on reducing the number of attendances at A&E with mental health crisis.

10 Increase number of patients engaging with mental health services earlier in their illness, i.e. before crisis point

See comments above and below. See comments above and below.

11 Increase number of patients with an agreed relapse prevention plan in place

At present little work has been undertaken to change clinical services and impact on this target, although the crisis care website (see comments above) has the potential to increase access by increasing the amount of information available to service users and their families, regarding what services they can use when dealing with a rapid deterioration in their mental health. As the Recovery culture and community connections work is further embedded it also has potential to impact in this area, by providing people with mental ill health with the tools and

There is considerable potential to build on the excellent working relationships which have developed across the four MERIT trusts and on the programme of work already established, to further impact in this area. The MERT website has on average of 5 hits with a recent increase to 10 on a daily basis. With refinement there is significant opportunity to dramatically increase the traffic and increase the impact on the local population.



programme to develop to full potential support to better manage their own condition.

12 Reduce unnecessary variation in crisis care services across the MERIT area

A Crisis Care website has been developed and launched which patients, carers and professionals can use to identify what services are available in their area, for crisis care. A considerable amount of work was undertaken to identify the crisis care services within each local area, which had not previously been mapped. During this time the Crisis Care page was visited 263 times, an average of 4.8 visits per day (recently increasing to 10 visits per day), much reduced traffic on weekend days with an average of 1.5 visits per day at weekends with 42% of these views were from NHS computers The next steps would be to undertake a fuller analysis of the services within the crisis pathway across the patch and identify how their effectiveness could be improved. However, there unlikely to be time to achieve this within the current programme.

The website is currently not well known about or used. It needs to be reviewed and improved e.g. better links from each Trust website. There is potential for it to be much more effective building on the clear foundations that have been put in place. There is potential to move forward to review the whole crisis care pathway, building on the work done to date and the good working relationships now in place. However, this is a large piece of work which would need clear scoping, planning and project support, to achieve.

13 Introduce shared clinical record

All of the ground work to implement shared access to clinical records across all four trusts has been completed. This includes putting in place both the technical, operational and Information Governance foundations. Shared approach stage one (patient demographic information), implemented on December 2018, involving Birmingham & Solihull Mental Health Foundation Trust and Coventry & Warwickshire Partnership NHS Trust. Dudley and Walsall

The current implementation can only provide limited benefits. To enable optimisation of all benefits, this programme needs to continue to full phase two implementation. As a next step Forward Thinking Birmingham (FTB) will be integrated into the shared access to clinical records.



programme to develop to full potential Mental Health Trust and Black Country Partnership Foundation Trust will come on board in the January 2018. The planning for phase two with delivery care plans and risk assessments is being undertaken and should be completed by end of March 2018. The implementation will occur in 2018/19. This phase will deliver significant clinical value giving staff access to key information to deliver effective quality care. This would give full access to clinical summaries and risk assessments across all four trusts.

WORKFORCE WORKSTREAM 14 Reduce

reliance on agency staff

From the baseline year of 2015/16, MERIT overall reduced its spend on agency nurses by 13% in year one and is on target to reduce by a further 20% in year two, if current trends continue. The trend by Trust is more variable with some of the MERIT trusts achieving much greater percentage reductions than others. Richard can you add something about the reduction in cost of locum medical staff

It is possible that a continuation of the closer working relationships and co-operation in this area could lead to further and faster reductions in agency spend than would be possible if each trust is competing in this area. E.g. if working in co-operation rather than competition finance directors can hold a clear line across the Alliance regarding what rates they will pay for locum doctors to reduce the change of agencies “gaming” and pushing rates higher.

15 Develop a joint approach to mandatory and other training

A training passport has been developed and recently implemented across all four trusts ensuring that staff who move between the Alliance trusts do not need to undertake duplicate statutory and mandatory training. Cost savings are being monitored, but it is anticipated that half a day’s time will be saved for each new member of staff joining from within the Alliance. The starters figures between the MERIT Trusts (Jan – Dec 17)

Now that this is set up and implemented, it makes sense to continue this as the longer it is in place and the more staff it affects then the more savings will be delivered. The training passport could be expanded out to the medical staff in particular doctors in specialist training. There is opportunity to develop a bespoke e-learning module for Recovery in response to a review of the



programme to develop to full potential across all staff groups for 12 months is 90. The number of people moving since the passport being introduced is 21. An analysis from DWMH on 4 new starters found a saving of £200. Further investigation shows that although the passport was introduced in September, the time lag in making offers via recruitment means that starters in September 17 would often be offered in June/July resulting in the low reporting of the passport to date. The data is captured quarterly and the next set of metrics will be available in March. Through the two joint MERIT / national recruitment events we had a foot fall of approximately 80 people translating into 25 offers and appointments and a further 30 contact details recorded for further recruitment.

current modules available.

16

Share best practices and approaches to recruitment of staff, with a focus on qualified nurses.

Vacancy rates across the MERIT trusts have stayed fairly stable during the period of the MERIT programme. Whilst best practice in recruitment and retention has been shared across the Vanguard. Trusts have implemented the TRAC system which improves time to hire, which identified earlier as an opportunity. No specific measures have been implemented on staff retention.

Continuing to work closely across the Alliance in future will enable further sharing of best practice in recruiting and retaining staff. Some specific areas where Trusts could work on include; Monitor and share recruitment activity, establish a system to utilise good candidates who weren’t required on the day, targeted recruitment campaigns, promote vacancies trough the MERIT website, engaging with academic institution, local community and labour market.



programme to develop to full potential 17 Improve staff

retention Comments as above. Comments as above.

FINANCIAL SAVINGS 18 Deliver

financial savings linked to a number of the above (specifically 5,9,12,14 and 15)

The MERIT programme has been funded by £3.05 million over two years from central NHSE funding, together with 1.02 million provided in staff release and backfill costs from the trust involved. To date the MERIT programme has saved £6.45 million.

To move forwards, as described above will require costs and resourcing, which will need to be fully understood and committed, by the organisations involved. Continuing with key aspects of the MERIT programme should enable further savings to be delivered, at the same time as providing real improvements to the care and experience of our patients and their families.

2.2 Recent feedback from those involved in the programme

Feedback from the people involved in the MERIT programme to date, both staff and service users, has been very positive. When asked why they had got involved with the programme, at a recent MERIT event, the overwhelming response was “..to improve services and make a difference for service users and carers…” They told us that the MERIT work had already achieved a great deal, including:

Creating networks across the patch Strengthening the focus on Recovery Demonstrating that our organisations can work together Raising awareness of mental health issues and reducing stigma Driving better partnership working, e.g. with WMCA Making strategic priorities clearer

And that seeing these programmes of work through would ultimately really benefit patients, carers and staff and save time and money.


Participants reported that vital to the progress of the programme had been:

Shared goals and a shared vision Clinical involvement and leadership Leadership and drive from the Chief Executives Joint working and organisations not being territorial Having dedicated funding and resources including programme and project management The involvement of service users and carers Giving people permission to make progress

1.3 Evaluation Conclusion The issues which prompted the initial application to become a Vanguard are as pertinent now as they were when this programme started. Patients are still being sent to inpatient beds, hundreds of miles away from their home when acutely mentally ill causing additional distress and problems for both them and the people who care for them. Out of area treatment days are as high now as they were before the programme started. Bed occupancy rates and A&E attendances with psychiatric disorder continue to demonstrate very high levels of demand for mental health services. Patients, their carers and their communities remain in need of help not just with treatment, but with their recovery. This is consistent with the national trend. The national funding together with the hard work of all concerned has enabled the MERIT programme to make substantial progress towards achieving the ambitious outcomes, outputs and targets that it set itself when the four trusts first came together. From a standing start, robust working relationship between the four trusts have been built up, and proved beneficial across the organisations. However, for a number of reasons, including reductions in funding available and elements of the programme taking longer to implement than anticipated, the full impact (as described in the outcome and outputs) has not yet been realised. If the NHSE funding for the programme finishes at the end of March 2018 much of this planned impact will not be fully delivered and gains may be lost. There remains vast potential to achieve more efficient and effective services, and continue to improve patient and carer experience, building on the MERIT legacy. This will only be achieved if all trusts continue to support ongoing delivery of key elements of the programme by setting clear goals, monitoring and evaluating the continued impact, identifying and committing resources to deliver and support delivery of the programme and continuing with the good working relationships and clear executive leadership which are crucial to success.


3.1 Agreed areas for 2018/19

Following the Steering Group meeting it was suggested that the following were the priorities for the remainder of the 2017-18 year, as well as remaining high impact areas for the mental health service users for 2018 and onwards:

1) Shared Patient Record – Phase 2 to include care plans and risk assessment 2) Bed management – Embedding the new system and processes across the organisations 3) Crisis Care Website – Enhancement of the current website and creating links to other networks and sites 4) Mental Health First Aid Training – development and implementation of an income generating function across MERIT 5) Staff Training Passport - Embedding this throughout the organisations

3.2 Benefits of ongoing work

To realise the benefits for MERIT, work is required to develop, complete, embed, and transition to business as usual during the course of 2018/19. A list of benefits which will be delivered through the five priority areas for 2018/19 are described below:

Crisis Care

The electronic shared health recover viewer is a single, modern, secure system which is able to access and display an integrated record from the current clinical systems allowing access to OOA patients. The bed management function is a coordinated approach between the four trusts supported by an electronic bed viewer providing bed status and occupancy levels. The Crisis Care website covers access to Mental Health services across MERIT delivering:

Improved Patient Safety - Patients admitted to inpatients based on need. More MH users identified at risk of reaching a crisis. Crisis services provide a holistic response. Inpatient care focussing on the acutely unwell. Patients spending less time in inpatient care

Improved Patient Experience - Care closer to home with fewer out of area (OoA) placements. Crisis services provide person centred joined up care. Fewer users requiring inpatient/restrictive care. Reduction in stigma and improved relationships with the wider community. Patients spending less time in inpatient care


Reduced costs to the MERIT collaboration and wider health economy - Fewer admissions, fewer OoA, reduced Length of Stay (LoS). Fewer users will have to visit A&E to receive crisis care and reduced A&E breaches. Reduction in time taken for crisis resolution

Mental Health First Aid - Help to reduce Mental Health stigma experienced by service users and the wider community. Potential Income generation through the delivery of MHFA. Increase people’s ability to manage their own mental health. Increase people’s ability to manage and support other people who are in mental ill health. Improved quality of life and service user experience. Supporting effective wellness and improved recovery. Reduction in complaints from patients and families. Improved employment opportunities across the region. Improved access into mental health services. Culturally responsive services.

Training Passport - Save time of staff in duplicating training and resources in providing repeat training. Value in hours saved in training for the list of statuary and mandatory course required by new starters.

3.3. Approach for 2018/19

To continue the programme activity in the priority areas the following resource will be required for 2018/19. The anticipated support costs for 2018/19 are circa £160,000. There will be no additional direct funding required by individual MERIT Trusts (excluding any further work required to include Forward Thinking Birmingham onto MERIT systems such as the electronic shared record viewer, which will be costed for FTB separately).

• Continuation of the CEO and Executives meeting through Steering Group on a monthly basis providing overall leadership and direction. • Clinical, Operational input through involvement through Clinical workstreams and Leads. Corporate services such as Finance, Evaluation,

Communication, Service Users and Carer, and Business Intelligence involvement through the Trusts. This is mainly through attendance at meetings and workshops which will involve time out for clinicians which is difficult to estimate which is anticipated to be significantly less than previous years.

• Maintain a scaled down programme team focused on supporting the five priority areas development, embedding and transition to business as usual.




Report Title: MExT Committee Chair’s Report

Committee:

MExT meeting held on 23 January 2018


Mr Mark Axcell, Chief Executive Officer Paul Lewis-Grundy Company Secretary


Decision / Approval

Gain assurance

Discussion

Information

Key issues and Risks MExT received a presentation outlining details of the recent visit of staff members to the Netherlands to gain an insight of the treatment given to mental health patients there. The presentation was well received and members were advised of areas of “good practice” and environmental changes that were being adopted within the Trust to further improve services based on learning from this visit. MExT received updates from:

• Chief Executive • HR Director • Nursing Director • Operations Director • Joint Medical Directors • Communications & Engagement Manager

The following matters were discussed:

• A Business Case for Transcranial Magnetic Stimulation • Service Line Reviews and Month 9 performance • The financial Position at Month 9 • Dissolution of the Walsall Section 75 Agreement • Peer Support progress updated • Community Survey results • Older Adults Inpatient Services capacity • Walsall Outpatient Activity

Enc 26 MExT Chair's Report (Final) Page 1 of 2

Interfaces with other Committees The business that was discussed by MExT interfaces with the following Committees/Groups:

• Audit Committee • Quality & Safety Committee • Finance & Performance Committee • Workforce Committee • Trust Board

Recommendations and requests for direction The Board is asked to receive this report from MExT for information and assurance.

Enc 26 MExT Chair's Report (Final) Page 2 of 2



Enclosure: 27

Report Title:

Committee Membership – Non-Executive Director Review – February 2018

Accountable Director: Harry Turner, Chair Author (name & title): Paul Lewis-Grundy, Company Secretary

Purpose of the report: To advise Board of the review of the Non-Executive Director membership of Board Committee’s and the resulting changes in membership

Action required from MExT Decision / Approval

Gain assurance

Discussion

Information


None


Not Applicable




Leadership culture






Caring Responsive Effective Well-led

The Committee membership is included in their Terms of Reference. It is important for the Non-Executive Directors role in scrutinising and holding the Executive Directors to account that there is adequate Non-Executive members on Board Committees

Safe

Enc 27 CommitteeMembership-NEDReview-Feb18 Page 1 of 2

Title Committee Membership – Non-Executive Director Review – February 2018

Introduction This report outlines the review of the Non-Executive Director membership of the Board Committees and informs Board of the changes made. Summary of key points, issues and risks The Trust has been carrying a Non-Executive vacancy since August 2017, which has meant that the Committee workload has been shared across fewer Non-Executive Directors. Following the confirmed appointment of Mr Harry Turner to Chair the Trust, a recruitment campaign is underway through NHS Improvement to recruit to the pre-standing vacancy on the Board, along with the vacancy created by Mr Turner being appointed Chair from his previous Non-Executive Director position on the Board. The campaign will also look to recruit an Associate Non-Executive Director to take up post following the always planned departure at the of March 2018 of Mr John Burbeck Currently the newly appointed Chair of the Trust is sitting on three Committees and Chairs two of those Committee’s, one of which he is the sole member. It is not governance practice for the Chair of the Trust to also Chair and report assurance to the Board on issues within the remit of the Board Committees. The Non-Executive Director membership of the Committees has therefore been reviewed and amended. Further detail The revised Committee membership to be effective immediately will be tabled at the meeting following discussion with the current Non-Executive Directors. The membership will be further reviewed following recruitment to the Non-Executive Director vacancies and Associate Non-Executive Director Recommendation That the Board notes for assurance the revised Non-Executive Director Committee membership. Action required The revised Committee membership is presented to Board for assurance. Enc 27 CommitteeMembership-NEDReview-Feb18 Page 2 of 2



Enclosure: 28

Report Title:

Trust Board and Committee Schedule 2018/19

Accountable Director: Harry Turner, Chair Author (name & title): Paul Lewis-Grundy, Company Secretary

Purpose of the report: To confirm with Board the schedule of the meeting dates for the Trust Board and Board Committees in 2018/19.

Action required from MExT Decision / Approval

Gain assurance

Discussion

Information


None


Not Applicable




Leadership culture






Caring Responsive Effective Well-led

It is good governance practice to have a forward schedule of Board and Board Committee dates to ensure the effective planning of Board and Committee business across the year, to meet the requirements placed on the Trust.

Safe

Enc 28 Board&CommitteeSchedule-2018-19Page 1 of 2

Title Trust Board and Committee Schedule 2018/19 Introduction This report confirms the Board and Committee schedule for 2018/19. Summary of key points, issues and risks The schedule of Board and Board Committee dates for 2018/19 has been prepared to ensure the effective transaction of Trust Business to meet its statutory requirements and priorities. The schedule of meetings has been planned in consultation with the Chair and the existing Chairs of the various Board Committees. Further detail The scheduled dates for Board and its Committees is included in the appendix Recommendation That the Board notes for assurance the schedule for the Board and Committees Action required The revised Committee membership is presented to Board for assurance.

Enc 28 Board&CommitteeSchedule-2018-19Page 2 of 2

TRUST BOARD DATES 2018/19

Date

Time Venue Paper Deadline

Thursday 5th April 2018

Public meeting 1pm – 3pm

Private Meeting 3pm – 5pm

Conference Room 1 Trafalgar House

47 - 49 King Street Dudley

DY2 8PS

Monday 26th March

Thursday

3rd May 2018



Boardroom Canalside House

Abbotts Street Bloxwich Walsall

WS3 3BW

Monday 23rd April

Thursday

7th June 2018





DY2 8PS

Friday 25th May (Monday 28th Bank Holiday)

Thursday

5th July 2018





WS3 3BW

Monday 25th June

Thursday 2nd August

2018





DY2 8PS

Monday 23rd July

Thursday 6th September

2017





WS3 3BW

Friday 24th August (Monday 27th Bank Holiday)

Thursday 4th October

2018





DY2 8PS

Monday 24th September

Thursday

1st November 2018





WS3 3BW

Monday 22nd October

Thursday 6th December

2018





DY2 8PS

Monday 26th November

Thursday 3rd January 2019





WS3 3BW

Friday 21st December (Xmas break)

Thursday 7th February 2019





DY2 8PS

Monday 28th January

Thursday 7th March 2019





WS3 3BW

Monday 25th February

FINANCE AND PERFORMANCE MEETING DATES - 2018

DATE TIME VENUE

22-Jan-18 2pm Canalside19-Feb-18 2pm Trafalgar26-Mar-18 2pm Canalside24-Apr-18 2pm Canalside

30-May-18 2pm Canalside25-Jun-18 2pm Trafalgar23-Jul-18 2pm Canalside

29-Aug-18 2pm Trafalgar24-Sep-18 2pm Canalside22-Oct-18 2pm Trafalgar26-Nov-18 2pm Canalside17-Dec-18 2pm Trafalgar

FINANCE AND PERFORMANCE MEETING DATES - 2019

28-Jan-19 2pm Canalside25-Feb-19 2pm Trafalgar25-Mar-19 2pm Canalside

MHA Scrutiny Committee 2018/19 Dates

Date Time Venue Paper Deadline

8th February 2018

2pm Conference Room 1, Trafalgar House

1st February 2018 (12:00 midday)

12th April 2018 5th April 2018 (12:00 midday)

14th June 2018 7th June 2018 (12:00 midday)

16th August 2018 9th August 2018 (12:00 midday)

11th October 2018 4th October 2018 (12:00 midday)

13th December 2018 6th December 2018 (12:00 midday)

14th February 2019 7th February 2018 (12:00 midday)

11th April 2019 4th April 2018 (12:00 midday)

Meeting Schedule for Quality and Safety Committee

DATE & TIME

9.00 am – 12.30 pm

VENUES DEADLINE FOR SUBMISSION OF

PAPERS/ACTIONS OUTSTANDING

12.00 noon

PAPERS TO BE DESPATCHED

10 January 2018 Board Room, Canalside House

Walsall 3 January 2018 5 January 2018

14 February 2018 Conference Room 1, Trafalgar

House 7 February 2018 9 February 2018

14 March 2018 Board Room, Canalside House,

Walsall 7 March 2018 9 March 2018

11 April 2018

Conference Room 1, Trafalgar House

4 April 2018 6 April 2018

9 May 2018 Board Room, Canalside House,

Walsall 2 May 2018 4 May 2018

13 June 2018 Conference Room 1,

Trafalgar House 6 June 2018 8 June 2018

11 July 2018 Board Room, Canalside House,

Walsall 4 July 2018 6 July 2018

15 August 2018 Conference Room 1,

Trafalgar House 8 August 2018 10 August 2018

12 September 2018 Board Room, Canalside House

Walsall 5 September 2018 7 September 2018

10 October 2018 Conference Room 1,

Trafalgar House 3 October 2018 5 October 2018

14 November 2018 Board Room, Canalside House

Walsall 7 November 2018 9 November 2018

12 December 2018 Conference Room 1,

Trafalgar House 5 December 2018 7 December 2018

9 January 2019 Board Room, Canalside House

Walsall 3 January 2019 5 January 2019

13 February 2019 Board Room, Canalside House,

Walsall 6 February 2019 8 February 2019

13 March 2019 Conference Room 1, Trafalgar

House 6 March 2019 8 March 2019

WORKFORCE COMMITTEE DATES 2018/19 All meetings to take place from 11am to 1pm, except the 27th April 2018 meeting which will take place at 9.30am – 11.30am DATE

VENUE DEADLINE FOR PAPERS (12 noon)

Friday 27th April 2018

Conference Room 1, Trafalgar House, Dudley

Friday 20th April 2018

Wednesday 30th May 2018

Wednesday 23rd May 2018

Monday 25th June 2018

Monday 18th June 2018

Monday 23rd July 2018

Monday 16th July 2018

Wednesday 29th August 2018

Wednesday 22nd August 2018

Monday 24th September 2018

Monday 17th September 2018

Monday 22nd October 2018

Monday 15th October 2018

Monday 26th November 2018

Monday 19th November 2018



Monday 28th January 2019

Monday 21st January 2019

Monday 25th February 2019

Monday 18th February 2018

Monday 25th March 2019


Audit Committee – 2018/19 meeting dates

Date

Time

Venue

Paper Deadline

Monday 21st May 2018 (Review & sign off of Financial Accounts)

11.00-13.00 (pre-meeting at 10.00am – Room 5 TH)

Conference Room 1, Trust HQ, 2nd Floor Trafalgar House, 47-49 Kings Street, Dudley, DY2 8PS

Monday 14th May

Thursday 21st June 2018 (Review & sign off of Quality Accounts)

10.00am-11.00am (pre-meeting at 9.00am – Room 5 TH)


Monday 11th June

Tuesday 18th September 2018



Monday 11th September

Tuesday 11th December 2018



Monday 3th December




Monday 11th March

Save the Date: 18th May 2016 for Turn the Page Review of Accounts – 2.00pm, Conference Room 1, Trafalgar House, King Street, Dudley.