Board of Directors - Lancashire Care NHS Foundation Trust Board/Web... · Board of Directors...

Board of Directors Tuesday 25 October 2016, 8:30am

Training Room 1 and 2, The Harbour, Windmill Rise, Blackpool, FY4 4FE

Board of

Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Training Room 1 and 2, The Harbour, Windmill Rise, Blackpool, FY4 4FE

Date Tuesday, 25 October 2016

Time 8.30am

PART ONE:

Reference Item Lead Action Enc FOIA

Exempt

PROCEDURAL ITEMS

TB 095/16 Welcome and opening comments Chair Verbal

TB 096/16 Patient Story Chair Verbal

TB 097/16 Apologies for absence and confirmation of quoracy

Chair Verbal

TB 098/16 Declarations of Interest Chair Verbal

TB 099/16 Minutes of the previous meetings Chair Decision Paper

TB 100/16 Action Tracker Chair Decision Paper

CHAIR AND CHIEF EXECUTIVES REPORT

TB 101/16 Trust Chairs Report Chair Noting Paper

TB 102/16 Chief Executive’s Report Chief Executive Discussion Paper

TB 103/16 Quality Committee Chairs Report Committee Chair Noting Paper

TB 104/16 Finance & Performance Committee Chairs Report

Committee Chair Paper

TB 105/16 Audit Committee Chairs Report Committee Chair Noting Paper

PEOPLE AND LEADERSHIP

TB 106/16 Quarterly Workforce Report Director of Human Resources

Noting Paper

FINANCE AND PERFORMANCE

TB 107/16 Quality & Performance Report Chief Operating Officer

Noting Paper

TB 108/16 Finance Report Chief Finance Officer

Noting Paper

GOVERNANCE AND ASSURANCE

TB 109/16 Board Assurance Framework including Risk Appetite Statement

Associate Director of Compliance and Assurance

Decision Paper

TB 110/16 Medicines Management Annual Report

Medical Director Decision Paper

TB 111/16 NHS Improvement Declaration – Q2

Chief Executive Decision Paper

Decision

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PART TWO:

TB 112/16 Minutes of the previous meeting Chair Decision Paper

TB 113/16 Chief Executive’s Report Chief Executive Discussion Paper

TB 114/16 Red Rose Corporate Services Quarterly Performance Report

Chief Finance Officer

Noting Paper

TB 115/16 Network Redesign Chief Operating Officer

Decision Paper

TB 116/16 Bed Modelling Outputs Chief Operating Officer

Discussion Paper

TB 117/16 Bay Health Partners Accountable Care Organisation

Chief Executive Discussion To Follow

TB 118/16 Our Heath Our Care programme update

Chief Executive Decision Paper

TB 119/16 Any other business Chair Noting Verbal

Date and time of next meeting Chair Noting Verbal

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Declaration of Interest – Board of Directors

Date of Declaration

Surname First Name

Job Title Nature of Interest

Do you envisage a conflict of interest between

outside employment and your NHS employment?

Nil Declaration

23/03/2016 Eva David Trust Chair

1.National manager Trade Union Congress 2.Wife is Director of HHM Design

Yes Unlikely but 1.TUC funds learning projects (E.G in relation to Apprenticeship) 2.HHM Design is an IT company that may tender for NHS work

20/04/2016 Tierney-Moore Heather Chief Executive

1.Director of Lancashire Sport Partnership 2.Trustee of NHS Confederation 3.Trustee of Community Integrated Care 4.Macmillan Allumni Patron 5.Breakthrough Mental Health Charity 6.Retained Consultant Glenview Capital Management

Yes Potential risk of CIC are bidding to provide services in Lancashire that are also of interest to LCFT

01/04/2016 Ballard Peter Deputy Chair & Non-Executive

Director

1.Hodson Consulting 2.Chief Executive DBE Service - (Some of our money may be used by the charities we support to help disadvantage children)

No

26/01/216 Furlong Gwynne Non-Executive Director

1. Director - Red Rose Corporate Services. 2. NED - Progress Housing Group 3. CEO of Regain Sports Charity 4. NED - Prospect (GB) Ltd. (Subsidiary of Riverside Housing Association)

No

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Declaration of Interest – Board of Directors

26/01/2016 Dickinson Louise

Non-Executive Director & Audit

Committee Chair

Talegar Limited No

06/01/2016 Wilson Isla Non-Executive Director

1.NED - Progress Housing Group 2.NED - Dallas Matthews Ltd 3.Director - Ruby Star associates Ltd 4.Shareholder – F squared Ltd 5.Self Employed work

No No specific conflicts envisages - any that arise will be declared

13/01/2016 Curtis David Non-Executive Director

Associate at Mersey Internal Audit Agency (Advisory Section)

No

09/11/2015 Gregory Bill Chief Finance Officer

Co-opted member of Lancaster University Finance and General Purpose Committee

Yes Potentially, if matters relating to clinical education arise, but unlikely to be a specific issue to LCFT.

08/04/2016 Roach Dee

Executive Director of

Nursing, Quality & Governance

11/03/2016 Marshall Max Medical Director

26/01/2016 Moore Sue Chief Operating Officer

08/02/2016 Gallagher Damian Director of HR

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BOARD OF DIRECTORS

Minutes of the Part One Board of Directors meeting held on 26 July 2016

PRESENT: David Eva, Trust Chair Heather Tierney-Moore, Chief Executive Isla Wilson, Non-Executive Director Bill Gregory, Chief Finance Officer Louise Dickinson, Non-Executive Director Max Marshall, Medical Director Sue Moore, Chief Operating Officer Peter Ballard, Deputy Chair Jo Alker, Deputy Company Secretary Dee Roach, Executive Director of Nursing & Quality Gwynne Furlong, Non-Executive Director Damian Gallagher, Director of Human Resources David Curtis, Non-Executive Director IN ATTENDANCE: Julie-Ann Bowden, Associate Director of Compliance & Assurance Ashley Christian, Governance Manager (minutes) Bev Pickover, Head of Communications

Louise Motley, Associate Director of Nursing (Colchester NHS Trust) Teresa Jennings, Appointed Governor Alan Ravenscroft, Public Governor Ashok Khandewal, Public Governor Tina Harkin, Director of Quality Academy (TB 078/16) Bridgett Welch, Associate Director of Nursing: Safeguarding (TB 079/16) Leon Leroux, Clinical Director Adult Mental Health (TB 085/16) Chris Sinnot, Director of Quality & Governance, Chorley Council (TB 084/16)

TB 066/16 WELCOME & OPENING COMMENTS

The Trust Chair opened the meeting and welcomed everyone, including three Governors and Louise Motley who was shadowing the Chief Executive. Introductions were made for new attendees. Anne Alison, Anne Moss, Julia Low and Rochelle Bentley joined the meeting.

TB 067/16 PATIENT STORY The Associate Director of Quality & Patient Experience introduced the members of the Falls Prevention Team who provided a detailed overview of the falls prevention car pilot. They discussed the examples of therapy interventions from the falls response service and the benefits of working jointly with a number of partners including NWAS as part of the pilot. These involved preventing patients from being admitted to acute beds unnecessarily and offering patients fast assessment of mobility and provision of support to meet their needs. The Board prompted discussion around the pilot being in line with the out of hospital strategy. Anne Alison, Anne Moss, Julia Low and Rochelle Bentley left the meeting

UNCONFIRMED

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TB 068/16 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY There were no apologies for absence. The Chair noted Naseem Malik was not in attendance and Board members had been notified of her resignation.

TB 069/16 DECLARATIONS OF INTEREST

Declarations were made by Gwynne Furlong and Bill Gregory for agenda item TB 089/16 Red Rose Corporate Services. Heather Tierney-Moore declared an interest in agenda item TB 083/16 Innovation Agency Quarterly Performance Report.

TB 070/16 MINUTES OF THE LAST MEETING

The minutes of the last meeting held on 26 April 2016 were taken as a true and accurate record subject to one minor typographical error being corrected.

TB 071/16 ACTION TRACKER

The Director of Quality & Nursing provided an update on the previous patient story heard by the Board in May and that the patient’s daughter is now involved in working with the Trust. The updated Decision Rights Framework would be circulated to the Board following changes to the definition of material.

TB 072/16 TRUST CHAIRS REPORT The Trust Chairs Report was taken as read. The Deputy Chair provided an update from Non-Executive Director Naseem Malik who was not in attendance due to her new role posing a potential conflict of interest. The Trust Chair and Chief Executive discussed the impact of Tommy’s story, the very positive feedback of his visit to the Harbour and meeting the staff.

TB 073/16 CHIEF EXECUTIVES REPORT

The Chief Executive discussed the upcoming CQC inspection and the expected outcome of the announced CQC visit to Liverpool Prison. Routine mental health act visits were also ongoing and would feed into the inspection. The Director of Nursing confirmed the Safeguarding Report had been received with no unexpected findings. A further update would be provided to Board next month. The Board discussed the governance declaration requiring Board sign off and would consider the Finance Report before approving. The Board discussed activity around the Urgent Care unit at Chorley and the plans being considered for the future of the accident and emergency department. The Chief Executive provided the business development update including Pennine Lancs vulnerable adults tender. An update on the prisons tender was provided and the Board noted the areas requiring further consideration before a decision on submitting a bid was made. A detailed bid would still be progressed whilst the Board considered the risks and reached a decision. The Chair of Audit Committee discussed the decision making around the prison tender and the reasons for arriving at the current position. The Chief Executive discussed the compounding influence of the CQC enforcement notices at Liverpool and Kennet inherited when the Trust took over interim management of the two prisons. The Chief Finance Officer discussed the tender specification produced by the commissioners and the Deputy Chair also discussed his view on the decision making.

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The Chief Executive highlighted an area of potential development relating to new and novel business which would require formal Board consideration in the near future. She went on to describe the draft Sustainability & Transformation Programme plan provided in confidence to the Board, discussing the accountable care model and the mapping work being undertaken in August.

TB 074/16 QUALITY COMMITTEE CHAIRS REPORT

The Chair of Quality Committee commented on the strengthened reporting and drew the Board’s attention to the serious incident annual report. Conversations at Quality Committee were leading to changes in the way the Board Assurance Framework is being mapped and the chair will also begin to attend Quality & Safety Sub-Committee to draw through assurances in the governance structure.

TB 075/16 FINANCE & PERFORMANCE COMMITTEE CHAIRS REPORT

The Deputy Chair introduced the report and discussed the robust consideration of the e-patient record programme due diligence process. The Finance & Performance Committee had considered the detail and was satisfied that a robust work programme had been developed to support the Board in signing off the E-PR contract which would also strengthen contract management and performance monitoring arrangements. A future Committee meeting would be convened to make a recommendation to the Board on approving the e-PR contract once all due diligence has been completed. The draft Estates Plan considered by the Committee had now been submitted for approval by Board later in the meeting. A recommendation from the Committee to hold a Board level discussion about financial information flows was also scheduled.

TB 076/16 AUDIT COMMITTEE CHAIRS REPORT

The Chair of Audit Committee attention to the cyber security report considered by the Committee on behalf of the Board and highlighted that the outcome of a self-assessment of ISO standards would be reported back to the Committee in due course. Work to review the scope of the Value for Money Framework was explained and the Board noted an internal review of the health and justice business unit was being arranged. The outcome would contribute to overall assurance on the system of internal control and would be considered as additional internal audit expenditure. The Annual Report of the Audit Committee was also presented and included priority areas for 2016/17 to include merger of the Trust risk forums to support triangulation of risk in the organisation.

TB 077/16 QUARTERLY WORKFORCE REPORT

The Director of HR highlighted encouraging performance around recruitment activity in line with the bank and agency plan. Improvements continue for core skills and mandatory training compliance. The 60 day time-to-recruit target had been met with work to continue to reduce this even further. The Quality Academy had achieved 95% of new employees attending induction within 4 weeks of commencing in post and feedback on the content of the induction programme has been positive. Assurance was also provided on completion of safe employment checks and employment standards.

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Sickness absence remains between 5% and 6% causing service disruption and increased bank and agency usage. The Board discussed the plan to improve workplace environments and provide additional HR support to managers on the ground in dealing with absence. The bank and agency spend was disappointing but presents a considerable opportunity to save money. Isla Wilson, Non-Executive Director fed back on the positive improvements being reported within the HR report. Another Non-Executive, Louise Dickinson also raised a query around the increase in bank and agency to understand the reasons for the spike in expenditure which would be picked up as part of the Finance Report. Tina Harkin joined the meeting.

TB 078/16 PEOPLE PLAN

The Director of Quality & Nursing introduced the item and noted the considerable work undertaken to develop the People Plan with staff and described how the People Plan will support the delivery of the Quality Led Strategy. The Director of the Quality Academy described the finalisation of the People Plan following extensive staff, service user and stakeholder engagement which ensured the final Plan reflects the voice of the people. Isla Wilson, the Non-Executive who has been heavily involved in the development stages of the Plan, reiterated the importance of driving forward the implementation and ensuring the Board retains the momentum. The Board discussed at length the importance of ‘Our People Plan’ for the right culture of the organisation and the interdependencies with assurance reporting within the governance structure. The Board approved the Trust’s People Plan. Tine Harkin left the meeting and Bridgett Welch joined the meeting

TB 079/16 SAFEGUARDING ANNUAL REPORT The Director of Nursing introduced the report. The Associate Director of Nursing for Safeguarding described the Trust’s duty of care for vulnerable people within Lancashire. She highlighted a positive year and the delivery of key priorities on time and to plan. Contractual and service delivery specifications were also being met and took account of newly introduced statute. The focus of the safeguarding service include domestic abuse, child exploitation and the PREVENT agenda, for which Lancashire has been identified as a priority area. The safeguarding agenda is expanding as a whole which is presenting challenges to the service, due to increased legislation and demand. The Chief Operating Officer commended the Safeguarding Service for the considerable work in maintaining robust safeguarding practice across the organisation and offering support to those who need it. The Board were very complementary of the case studies within the annual report which bring to life the importance of the safeguarding agenda. A query was raised around compliance levels for safeguarding mandatory training and the actions being taken to improve compliance. The Associate

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Director shared details of training provided by LCFT to external organisations including GPs and potential to market a training package more widely. The Trust Chair prompted a discussion on the Trust’s involvement in delivering elements of the PREVENT agenda in Lancashire both in the county and nationally. The Deputy Company Secretary provided an overview of the voluntary statement presented in response to the new Modern Slavery Act. The Board noted the statement was supported by the Associate Director for Safeguarding and approved the modern slavery declaration. The Board formally received the Annual Safeguarding Report. Bridgett Welch left the meeting.

TB 080/16 QUALITY & PERFORMANCE REPORT

The Chief Operating Officer provided an overview of the key highlights in the Quality & Performance Report. The waiting time for IAPT was confirmed as compliant with NHS Improvement targets and currently stood at approximately 11 weeks. Following a query from Non-Executive Director Louise Dickinson, it was confirmed that 90% of outstanding CQC actions are complete and being validated. The expectation is that there will be no outstanding actions for CQC in next Quarterly Performance Report. The process to hold Networks to account on delivery of actions was described.

TB 081/16 FINANCE REPORT

The Chief Finance Officer outlined the Trust’s financial position and also the new report from NHS Improvement about financial improvements. The Trust is £1.6m behind plan with a significant component of expenditure being temporary staffing. While the Trust remains off plan it is not eligible to access additional funding from the STP which pushes the position to approx. £2m off plan. A discussion about the components of bank and agency spend took place. Work to incentivise internal staff to work through staff bank has seen an increase but agency staff has not reduced. The Chief Finance Officer explained the additional plan which had been produced to allow the Board to consider the mitigations needed and control of temporary staffing was a key feature in the report. Engagement was taking place with networks to apply further controls around temporary staffing levels and expedite delivery of the DTS programme and other cost savings. A wider senior management session would also identify immediate priority areas to expedite. The current OATs position and spend against the agreed £4m was discussed alongside the generation of additional risk to the position. The Board noted the Trust’s overall financial risk rating would be 3 if the control total is achieved.

The Chief Executive invited the Chief Operating Officer and Director of Nursing to discuss the reasons for the bank and agency position. The work around safer staffing and rostering alongside other variables affecting the position were noted. A national issue exists in recruiting enough qualified nurses because of a lack of university places being commissioned. She explained other opportunities to

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explore included more effective planning for leave and training which is being undertaken by the Nursing Directorate. New protocols may also require a second approval of any extra staffing in clinical areas to strengthen controls around agency usage. The Chief Operating Officer outlined work to utilise staff trained in e-rostering to support teams to allocate staff more effectively. Heads of prison healthcare were being supported to understand need for qualified and non-qualified staff. A decision has been taken to auto-enrol staff onto the clinical bank for new recruits under an opt-out scheme. Recruiting managers are being provided with clear directions for the consistent application of safe and sustainable staffing principles and temporary staffing. Confirmation from Networks has been provided that there are no agency workers filling administrative posts. There remains an issue to understand if additional staffing levels are necessary due to increased acuity of patients and anecdotal evidence is being tested to consider the evidence for support this. The reasons for the upsurge in agency spend within an otherwise steady trajectory was raised by the Chair of Audit Committee. A strong message to senior managers has set expectations that action is taken and the temporary staffing figures reduced. The Chair of Audit Committee expressed concern about the Trust’s ability to achieve the agency cap based on current spend. Confirmation was provided that internal agency targets have been reset to take into account the current spend and in order for the agency ceiling to be achieved. A discussion took place about the recovery of debt from local authorities affecting the Trust’s financial plan. The Board will continue to reflect on the risk to cash and liquidity and compounding bank and agency spend. The Chief Operating Officer also reflected on the high occupancy levels affecting financial position due to only receiving funding for running at 80% occupancy. The importance of the Board regularly scrutinising financial information was emphasised by the Chief Executive and supported by the Chair of Finance & Performance Committee. An action was taken to convene a working group to allow the Board to solely consider the response to the financial situation and monitor improvements. The Chief Finance Officer referenced the changes applied to the monitoring regime by NHS Improvement. He recommended a robust financial recovery plan be developed to inform discussions with regulators. Louise Dickinson left the meeting

TB 082/16 INNOVATION AGENCY QUARTERLY PERFORMANCE REPORT

The Chief Executive presented the report which provided assurance to the Board that the hosted organisation is performing on plan. The Board approved a request to delegate scrutiny of future quarterly innovation reports to Finance & Performance Committee. The annual report and business plan would remain with Board for receipt and approval and any issues would be escalated by Finance & Performance.

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TB 083/16 BOARD ASSURANCE FRAMEWORK The Associate Director of Compliance & Business Assurance introduced the report and noted the important step in bringing together the two risk forums to support triangulation of risk and cross cutting risks. She introduced the Q1 BAF report and the challenge to achieving some risk target scores. The Board discussed the role of sub-committees in seeking assurance about the mitigating actions in place to pull back on the scoring matrix. A question was raised by a Non-Executive Director about the impact of assessing the likelihood of risk materialising being the key factor in controlling the risk score and how this contributes to the way the risk register system functions when assessing catastrophic outcomes of risks. The Board approved the Quarter One Board Assurance Framework.

Leon Leroux joined the meeting

TB 085/16 PATIENT FLOW MODELLING PROJECT

The Medical Director provided the background to the bed modelling project undertaken with North East London FT (NELFT). The Clinical Director for Adult Mental Health provided a detailed overview of the work to develop a software model that is able to simulate various service model configurations in order to see the operational impact on bed numbers, community teams, finance etc. The findings of the benchmarking exercise undertaken between the Trust and North East London FT were set out. Significantly, Lancashire Care is receiving the highest number of referrals in the country (amongst mental health trusts) and retains 98% acceptance of patients. A figure which is 2.7 times the national average meaning CMHTs are 30% busier. The Clinical Director presented the comparison between the mental health patient profile of NELFT and LCFT, and the other NHS organisations in the North West. It was highlighted that NELFT had taken eight years to reach their current bed occupancy rates and importantly had a self-referral model which promoted so-called ‘easy in, easy out’ access to mental health services. A summary of the key benchmarking data was provided for community teams, crisis teams and acute admissions. The Medical Director discussed how the findings relate to the Trust’s options for revising the bed model in order to meet demand. Ongoing dialogue with commissioners will include discussion on how the Trust can better manage demand and acuity. A discussion followed about the reasons for the high demand and the various factors which contribute to mental health prevalence amongst certain population demographics. Clarity was provided on how the benchmarking findings have been introduced to commissioners and the initial response to suggestions to change the bed model. Peter Ballard left the meeting. The Public Governor for Blackpool discussed his knowledge of mental health needs which support the data findings.

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Healthier Lancashire and the STP could present a options for taking the bed modelling forwards. Discussions about creating capacity within crisis teams to reconfigure and provide virtual wards could be tested using the mathematical system which allows the impact to be seen before changes are made. Max Marshall left the meeting. The Trust Chair requested a fact sheet which would help Governors and staff with the key messages about bed modelling from the Chief Operating Officer. Leon Le Roux left the meeting, Chris Sinnet joined the meeting.

TB 084/16 CHORLEY REFORM BOARD

The Chief Operating Officer introduced the item and a video was shown to the Board of a patient story. It reflected the positive impact of small, early interventions with mental health patients preventing a spiral into mental health services. The Chief Operating Officer outlined the proposal for an integrated community wellbeing service, the business case for which had already been considered by the Board in November 2015. The proposal was seeking Board approval to establish the wellbeing service, seek a non-executive director to join the joint executive group and endorse the reporting of the service via the DTS paper scrutinised at Finance & Performance Committee. Members of the Board were supportive of the proactive strategy to connect services in order to support the population. The Chief Executive discussed the potential for the integrated service to expand and involve more partners but the proposal at this stage had pragmatically chosen to partner and make progress given both organisations’ ability to commit to, and drive change. It was noted that the footprint of the pilot was relatively small but the depth of the pilot was unique. The Board approved the proposal. Chris Sinnet left the meeting.

TB 087/16 QUARTERLY NHS IMPROVEMENT DECLARATION

The Board noted the quarterly governance declaration is entirely consistent with the Trust plans. The Board agreed to provide a supporting narrative with the declaration to NHS Improvement given the risks the Trust is carrying risks to the financial target and bank and agency target. The Board approved the declaration. The additional narrative would be prepared and signed off by the Chair and Chief Executive before submission to NHS Improvement.

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Board of Directors

Agenda Item TB 101/16 Date: 25/10/2016

Report Title Trust Chairs Report

FOIA Exemption No Exemption

Prepared by Umme Batan, Corporate Governance Support

Presented by Peter Ballard, Deputy Chair on behalf of David Eva, Trust Chair

Action required Noting

Supporting Executive Director Chief Executive PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by the Board and Non-Executive Directors in addition to Board meetings. The Board are also asked to ratify the decisions made at the informal Board meeting as highlighted in red in the report.

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence

CQC domain Well-led

1.0 INFORMAL BOARD SESSIONS Since the last formal Board of Directors meeting held on 26 July 2016 Board members have attended two Informal Board Development Sessions;

Board Development Session – 31 August 2016

Sarah Jayne Programme Director for Our Health Our Care provided an update on the objectives of the programme to deliver person centred model of care and set out the governance structure of the joint programme board. The Board also considered the QPR, Chief Executives Report, Finance Report and approved the Well-Led action plan and the monitoring arrangements. The Financial Recovery Plan and Financial Improvement Measures were also discussed in detail.

Board Development Session – 27 September 2016

Tim Crowley Managing Director for Mersey Internal Audit Agency (MIAA) introduced a session on risk appetite which will inform the Board’s refresh of its risk appetite. A patient story about district nursing telephone triage was heard and the Board considered the Chief Executive Report, QPR and Finance Report. The Board formally ratified the Substantial Level Statement of Compliance and Improvement Plan as signed off by the Accountable Emergency Officer (Executive Director of Nursing and Quality).

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2.0 Use of the Common Seal To inform the Board that the Common Seal has been used as follows since the Board meeting on 26 July 2016:

26 July 2016 - Partnership Agreement under Section 75 of the NHS Act 2006. Section75 Agreement between Lancashire Care NHS Foundation Trust and Lancashire CountyCouncil.

30 August 2016 – Contract and transfer re sale of residential property 7 Daisy Bank,Lancaster

14 October 2016 – Lease relating to land and buildings at Friday Street betweenLancashire Care NHS Foundation Trust and Bugle Inn Motor Company Ltd

3.0 NON-EXECUTIVE DIRECTOR VACANCY

The Council of Governor’s Nomination Remuneration Committee continue to oversee the recruitment process for the Non-Executive Director vacancy. The Trust is currently managing the recruitment process in order to keep costs minimal and has engaged the expertise of the appointments team at NHS Improvement to help attract candidates. The advert is open until 30 October 2016 and can be viewed here. So far there has been a positive response from interested candidates and interviews will be scheduled shortly.

4.0 GOVERNOR ELECTION

The Notice of Election has been published for the forthcoming public seats in Blackburn with Darwen, Central, East and Out of Area and staff in corporate and medical. Nominations close at 5pm on 1 November and the results will be announced on 9 December.

5.0 DIRECTOR ACTIVITY

In addition to the usual Board business, Non-Executive Directors (NED) have been involved in their areas of special interest during the period of July 2016 – October 2016:

All Non-Executive Directors have been attending the Board Committee meetings of which they are a member and apologies have been given where they were unable to attend.

Peter Ballard deputised for the Chair and attended an ACC panel interviews he also deputised at the Pennine Lancashire Transformation Programme System Leaders Forum meeting. He deputised for the Chief Executive and attended the Lancashire Sports Awards Judging panel. Peter attended and chaired the Financial Recovery Group meetings. Louise Dickinson had her monthly meetings with the Chief Executive and she met with the Associate Director of Compliance and Assurance and the Associate Director of Safety and Quality Governance to discuss risk management & assurance. She also attended a Good Practice Visit to Wordsworth Terrace. David Curtis attended the Making Our Pledges with Tommy Whitelaw and also carried out a shift in Bronty Ward at the Harbour. He took part in the AHP stakeholder panel interviews with the Director of Nursing and met with several Executive directors to discuss the Network re-design. David attended the Specialist Services Network Assurance & Governance Committee meeting and the Quality and Safety sub-committee meeting as an observer. He had a tele-call with Paula Turner from NHS NWLA and attended the Integration: Vanguards - New Models of Care event. As part of the CQC interview preparation David met with Melanie Gavin. Gwynne Furlong met with the Chief Executive to discuss the Estates Plan and attended the Financial Recovery Group meeting in October and attended a Good Practice Visit to St Georges Surgery. Gwynne and the Stakeholder Engagement Manager met with the Operations Director and the

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https://www.jobs.nhs.uk/xi/vacancy/d60fb75aaee0ee9f68c2ad9e09a4d520/?vac_ref=914352872

https://www.lancashirecare.nhs.uk/governor-election-2016

Senior Project Officer from the Inter Madrassah Organisation charity to discuss ways of developing effective links between the organisations. He also attended a visit to HMP Lancaster Farms with the Chief Operating Officer. Isla Wilson had several meetings with Executive Directors and senior managers. She attended a Good Practice Visit to HMP Kirkham and also carried out a visit to HMP Preston with the Chief Operating Officer. All Non-Executive Directors met with the Chief Operating Officer and the Director of Nursing and received a briefing on the Specialist Services Network update. They also participated in the NED CQC focus group. David Curtis was interviewed separately. Peter, David and Louise attended the chairs meeting with the Trust Chair. David and Isla attended the Quality Account Development Session.

6.0 CHAIRS ACTIVITY

The Chair attended the Board meetings, Council of Governors meeting and CoG Nomination Remuneration Committee meetings and also attended the Financial Recovery Group meeting in October. David took part in AAC panel interviews. He also attended a meeting with Staff Side reps The Chair has been having weekly catch up meetings with the Chief Executive and monthly meetings with the Company Secretary. He met with Board members and also had CQC pre inspection meeting with Melanie and attended the day zero CQC presentation and had an interview with CQC inspectors. The Chair attended the Pennine Lancs Transformation System Leaders Forum meeting and Making our Pledges with Tommy Whitelaw event at The Harbour and attended the Leyland Health Mela. He carried out prison visits with the Chief Operating Officer to HMP Garth and HMP Wymott. He also attended the Thinking Space event. He attended a HFMA Chair and NED Faculty Forum and a Chairs and CE network meeting in London. David attended the World Mental Health Day event which was organised by UCLan

The Chair continues to have his introductory meeting with senior managers, external stakeholders, MPs, CCG and Local authorities,

7.0 BOARD ACTION The Board are asked to ratify the decisions made at the informal Board meeting as highlighted in red in the report.

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Board of Directors


Report Title Chief Executive’s Report FOIA Exemption Part Exemption Business Development Report Prepared by Heather Tierney-Moore, Chief Executive Presented by Heather Tierney-Moore, Chief Executive Action required Discussion Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT:

Report purpose The purpose of this report is to provide Board members with an overall summary of the Trust position and highlight areas for further discussion.


To provide high quality services

Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

CQC domain Well-led

Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally.

QUALITY AND SAFETY

The Building Blocks to Effective Continuous Quality Improvement across an organisation. (Dr Peter Chamberlain ©) As previously noted we are one of two organisations in the North West working with Dr Peter Chamberlain and AQUA to pioneer and support further testing of the Building Blocks Framework. The framework helps us to translate what can be quite abstract concepts into reality with examples of initiatives used by leading edge organisations. The Building Blocks Framework (BBF) identifies the twelve key components of a quality improvement focused organisation. The starting point for us was to identify which of the components are our key areas of focus for the remainder of this first year and on into year two of the Quality Plan.

A thinking space session was held on Friday 30th September involving colleagues from our clinical teams, networks and support services. The session was facilitated by Dr Peter Chamberlain and attended by the Director of Nursing and Quality and the Trust Board Chair. The session involved assessing ourselves using the Building Blocks diagnostic tool which gave us our baseline and informed our next steps. The BBF areas which will be taken forward as part of bringing our Quality

Plan to life are:

Person and Family Centred Care: Moving from ‘what’s the matter’ to ‘what matters to you’ Co-design improvements with people who use our services, carers and families

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Cultural and infrastructure essentialsValued workforce Including psychological safety Increasing staff capacity and capability in quality improvement

Learning system essentials Model for improvement active at the frontline Real time transparent measurement and understanding of variability

The Quality Plan is being refreshed to reflect these goals and associated actions. The Quality Team will share an update with Dr Peter Chamberlain and AQUA and secure support in progressing and achieving these goals.

‘Sit and See’ A key goal within the Quality Plan, to support us all in keeping ‘people at the heart of everything we do’, is to help everyone to connect with the core purpose of the organisation and to give people who are somewhat distant from the point of care on a day to day basis, the opportunity to ‘sit and see’ different aspects of our clinical world. This approach supports us in understanding what compassion looks like and gives us a way of measuring it using the ‘sit and see’ observation tool. The training will help us to see care through the eyes of a person using a service, how care and compassion can be demonstrated and the difference this makes.

A ‘Sit and See’ foundation course is taking place on the 31st October 2016 involving 15 participants with representatives from across support service areas. They will be committing to the learning programme and will undertake a minimum of 6 observations session across the year. A ‘Sit and See’ observation calendar will be in place from December 2016 onwards. There will be opportunities for Board members and Governors to ‘buddy’ with trained colleagues to engage in ‘Sit and See’ observations throughout the year.

Good Practice Visit: One Good Practice Visit has taken place during this reporting period and a summary of the visit is given below:

HMP Kirkham: visited on 13th September 2016 The visiting team: Damian Gallagher: Director of Human Resources Louise Dickinson: Non-Executive Director Isla Wilson: Non-Executive Director Katherine Wykes: Public Governor Michelle Prescott: Quality Improvement Lead Julie Garlick: Quality Officer

The Healthcare Team at HMP Kirkham provides health education, prevention, and physical and mental health intervention as required for 630 male prisoners in a standalone health care building. The team predominately provide initial and ongoing health care assessments to measure and maintain people’s health and wellbeing. This also includes medication management and monitoring. The team make active use of their Team Information Board which contains important messages, updates, training resources, performance information and the number of prisoners attending healthcare sessions. Compliments received from patients are displayed and include cards, poems and pictures. The Team Information Board supports conversations at the regular team huddles supporting ideas for service improvements:

People at the heart of

everything we do

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o Changes have been made to operational hours to support the needs of the increasingly olderpopulation of prisoners.

o Following a review of prisoners failing to attend healthcare appointments, a new system forsending out appointments has been introduced. A new triage system for GP clinics has led toimproved attendances.

o A new housekeeper role now oversees the cleaning rota. This has led to clinic areas beingcleaned promptly and clinical sessions commencing promptly and without interruptions.

The team reported good relationships having been established with Human Resources. They work together to overcome any challenges which arise, particularly during the recruitment process.

The Team Leader spoke about staff retention and the work she undertakes spending time with new members of staff, supporting them until they feel confident about their working environment. The Team Leader has an ‘open door’ for staff to share any concerns and ideas to ensure that everyone feels safe in their work.

The visiting team acknowledged the good practice reflected by the team and encouraged them to continue to capture this work which will support them when they move to a new contract.

Clinical Procurement Nurse It has been recognised that Clinical procurement nurse specialists lead nursing and other clinical teams through change management and decision making processes ensuring that quality, safety and value are delivered in procurement project outcomes. A clinical procurement nurse specialist can use their experience of delivering patient care to enhance procurement knowledge and support patient focus in the contracting and product selection process.

Lord Carter’s review of operational productivity in NHS providers in 2015 also highlights that recent joint work by the Royal College of Nursing (RCN) and the NHS Supply Chain shows that nurses working together with Procurement Managers could save more than £30m per annum – the equivalent of 1,000 nursing jobs – just by streamlining the buying of basics such as wipes and incontinence products. Lord Carter has worked with 22 hospitals to see how the NHS could save money by improving efficiency and sharing best practice. It is acknowledged that whilst not on the same scale as identified within the acute sector there are also significant opportunities to improve patient and staff safety, quality of clinical products and improve efficiency within the Mental Health and Community settings.

The role of the Clinical Procurement Nurse Specialist is cited by the RCN as an effective means of securing the levels of engagement necessary to realise these efficiencies locally. To date, Nicky Morton, Clinical Procurement Nurse has achieved the following:

Standardisation of advanced wound dressings Enteral feeding and suction consumables review Standardisation of single use sterile scissors Review of Procedure Packs to identify £10,000 reduction in spend Review of the use of continence products in the inpatient setting Analysis of spend on first dressing initiative Proposed Introduction of LCFT Total Purchase Scheme for Wound Dressings Evaluation and implementation of safer sharps legislation Coordination role / interface between LCFT and the Commissioning Support Unit - outsourcing

of medical community equipment Engagement with the National Clinical Evaluation Team (NHS England) Engagement with the Clinical Procurement Specialist Network Engagement with the RCN Small Changes / Big Difference Campaign Overview of Projects/ reduction in spend since introduction of Senior Nurse Procurement Role

(Quarter 3 - 2015/16)

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FINANCE AND PERFORMANCE

Quality and Performance Report The full Quality and Performance Report will be circulated to the Board on Friday, 21 October 2016.

Financial Position

Month 6 sees a year to date operating deficit of ‐£3.1m, £2.4m behind plan for the year. £1.0m relates to Sustainability and Transformation funding which can be recovered when the Trust achieves its financial targets. It is projected that the full year operating deficit after mitigations would be £1.4m, but this is not without risk and without mitigation the Trust is in line for a £7.8m overspend. The month to month position also shows some deterioration, primarily as a result of the five week month impact on temporary staffing and deteriorations in the Community and Children's & Families networks; overspends in ward areas remain an issue as do risks around OATs.

The full finance report can be viewed here.

PEOPLE AND LEADERSHIP

External Engagement The Quarter 2 Communication and Engagement report is attached here. A theme emerging from CCG AGMs is the challenge from members of the public about awarding contracts to non-NHS providers. This is likely to play out further as LDPs and the Lancashire and South Cumbria Change Programme start meaningful public engagement about proposals within the STP. Another continuing theme is the positive feedback from GPs about services that are perceived to be localised.

The majority of media coverage in Q2 was again positive, although negative coverage about an inquest about a patient at The Harbour and a shortage of Mental Health beds nationally had high impact.

The increasing trend of people accessing the Trust’s website using mobile devices continues and in Q2 the majority of site visits came from mobile devices for the first time. If this trend continues, the majority of visits will be soon be from mobile phones.

Awards The National Positive Practice in Mental Health award ceremony took place on 13 October 2016 and LCFT staff won two awards and were highly commended in another category.

Andrew McCrimmon, deputy team manager and senior mental health practitioner within an integrated neighbourhood team was joint winner of the ‘Making a Difference’ award. This was in recognition of his ability to sustain high standards of technical and clinical service developments. Older adult mental health colleagues also achieved a win in the category of Mental Health Integration in Five Year Forward View New Models of Care for work to align services and deliver whole person health, linking with the Extensivist Team in the Fylde Coast and Better Care Together in the North.

The Always Events co-design team were highly commended for the work jointly done between learning disability services and colleagues from the quality directorate to further develop various points in the clinical pathway as chosen and redesigned by service users themselves.

GOVERNANCE AND ASSURANCE

NHS Improvement – Quarter Two The Quarter Two monitoring return has been submitted to NHS Improvement and as per conversations at the Finance Recovery Group, this has been supported by narrative that outlines the

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key risks to the achievement of the recovery plan. The detail of the submission can be seen at agenda item TB 111/16.

Strengthening Financial Performance & Accountability On the 21 July 2016, NHS Improvement and NHS England published the document ‘Strengthening Financial Performance and Accountability in the NHS’, which set out the need to stabilise finances in the NHS and start an expenditure reduction programme in 2016/17. The document outlines the protocol to be followed should an FT consider revising its financial forecast during the year. Changes can only be made once a Trust’s plan for the year has been approved and only at Q2 and Q3. As part of the reporting, the Trust must ensure it engages with relevant commissioners, the senior clinical decision marking body and the Executive and Finance Committees and the Board. The clear drivers for the change in forecast must be prepared along with the actions being taken to address the deterioration. The full protocol can be viewed here.

The Finance Recovery Group continues to scrutinise the financial position on a monthly basis.

Well-Led Action Plan In August, the Board approved the action plan developed to address the recommendations made within the Well-Led Report and the process to monitor the delivery of the action plan. The document attached here draws out the actions that were scheduled for delivery during August andSeptember. All actions have been completed and evidence has been collated to support this.

Board Assurance Framework (BAF) The BAF risk register has undergone a full review and the end of Q2 position is provided in the Board pack. During Q2, the challenges of reducing bank and agency spend has impacted on the scoring of BAF risk 4.1 and the score has increased from 15 to 20. Two risks have reduced in score as a result of additional controls and assurances identified during Q2. BAF risk 1.2 has reduced from 16 to 12 and BAF risk 4.2 has reduced from 12 to 9. Detail relating to this can be reviewed in the full BAF report under agenda item TB 109/16.

Risk Appetite Statement The Board Development Session in September provided an opportunity to consider the currency of the Trust’s Risk Appetite Statement which was approved in October 2016. The session facilitated by Mersey Internal Audit Agency included focusing on three of the current priorities to explore and debate the views of the Board of Directors and members of the Senior Management Team. In addition, consideration of how the risk appetite can inform and influence decision-making provided valuable discussion that will support the process of reviewing the Risk Appetite Statement moving forwards. The refresh of the strategy is nearing completion with a view this this being finalised during Q4 of the current year. The review of the Risk Appetite Statement is interrelated with this process and the Board of Directors will have the opportunity to consider a refresh of the Risk Appetite once the strategy has reached a stage for this to happen.

BUSINESS DEVELOPMENT

Our Health Our Care Programme Update The detailed report provided to the Board under Part Two gives an update on the progress of the Our Health Our Care programme. The programme has made great progress over the last period, closing the mobilisation phase and moving into solution design phase. Momentum and energy around the programme are high and we look to move through the next phases of the programme.

Much work has been undertaken around stakeholder engagement and the process for external assurance, and we will look to build on this going forward. The STP process and Healthier Lancashire and South Cumbria continues to be an area the programme must be mindful of and manage the interdependencies. Key risks have been identified regarding stakeholder relationships, interdependencies with the Healthier Lancashire and South Cumbria Programme, the focus of

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http://www.lancashirecare.nhs.uk/media/Trust%20Board/Web-Page-Docs/26.10.16/TB%20102%2016_2016%2010%2013_Well-Led%20Action%20Plan_Sept%2016.pdf

programme on transformation whilst ensuring sustainability, linking the operational business and contracting to the change programme, and public perceptions.

The paper also provides the Memorandum of Understanding, now referred to as the ‘Partnership Agreement’ for information.

Lancashire and South Cumbria Sustainability and Transformation Plan The Trust has received clarification about the timetable for the submission of the Lancashire and South Cumbria Sustainability and Transformation Plan (STP). The STP will be taken to the system-wide Programme Board for sign off on 19 October and then presented at the first meeting of the Joint Lancashire Health and Wellbeing Board on the same day. The final draft submission will then be available for Lancashire Care to use in internal or health economy meetings but not for external meetings or publication on the Trust’s website. Between 26 October and 15 December, it is anticipated that all 44 STPs will issue a public summary of their current position via the public board meetings of the statutory bodies involved. To ensure that the Lancashire Care Board publishes an accurate and consistent summary of the current position, the Trust will be provided with both a detailed summary of the plan and proposals for stakeholder engagement about the plan, including the public, NHS staff and political leaders.

Bay Health and Care Partners Accountable Care Organisation Section 22: Information Intended for Future Publication

Section 22: Information Intended for Future Publication Lancashire Prison Demobilisation

Nursing Associate Bid

Health Education England (HEE) have introduced a new two year programme for trainee Nursing Associates. This new role will sit alongside existing nursing care support workers and fully-qualified registered nurses to deliver hands-on care for patients. LCFT submitted a bid to be one of the 11 sites to deliver the first wave of training however; we have been informed that our bid was unsuccessful. HEE have explained that the standard of the applications were incredibly high making it a difficult task to narrow down the selection. HEE will be running a second wave of a further 1,000 nursing associate trainees through ‘fast follower’ test sites starting in Spring 2017 and the trust will be part of this cohort.

Health Education England (HEE) have introduced a new two year programme for trainee Nursing Associates. This new role will sit alongside existing nursing care support workers and fully-qualified registered nurses to deliver hands-on care for patients. LCFT submitted a bid to be one of the 11 sites to deliver the first wave of training however; we have been informed that our bid was unsuccessful. HEE have explained that the standard of the applications were incredibly high making it a difficult task to narrow down the selection. HEE will be running a second wave of a further 1,000 nursing associate trainees through ‘fast follower’ test sites starting in Spring 2017 and the trust will be part of this cohort.

FOIA Exempt Under Section 43 – Commercial Interest Business Development Report

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Board of Directors


Report Title Quality Committee Chairs Report


Prepared by Jo Alker, Company Secretary

Presented by David Curtis, Chair of Quality Committee


Supporting Executive Director Chief Executive


Report purpose To provide an outline of the activity undertaken by the Quality Committee, highlight assurance received and risks identified.



Board Assurance Framework risk 1.1 The Trust does not protect service users from avoidable harmand fails to comply with the CQC standards for the quality and safety of services 1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Board level Quality Committee on 18 October 2016.

2.0 BOARD ACTION The Board of Directors is asked to note the content of the Chair’s Report for assurance.

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CHAIRS REPORT

CHAIRS REPORT OF: QUALITY COMMITTEE

DATE OF MEETING: 18th October 2016

BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO SUB-COMMITTEE:

1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services.

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services.

3.1 The Trust fails to deliver holistic whole person care (Physical and Mental Health).

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care.

7.3 The Trust does not comply with Mental Health Legislation.

AGENDA ITEMS BAF RISK DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Board Assurance Framework (BAF)

1.1, 1.2, 3.1, 4.1, 4.2, 7.3

Quality Committee considered the BAF risks aligned to the Committee along with the risks scored 15 above. Committee members were asked to note the risks when considering the assurance received throughout the meeting and any newly identified or changed risks. Committee members noted that the Q2 BAF would be presented to the Board in October. Comments were made in relation to the consistency of language and assessment of risk scores particularly in areas where the same risk had been identified and the Director of Nursing and Quality outlined the work scheduled during Q4 to review and address this. The role the Risk Forum played in providing support in this area was also noted.

Raising Concerns 1.1, 1.2, 4.1 Quality Committee were provided with a six monthly update in relation to Raising Concerns activity. The Committee noted that during April-September 2016 there had been 39 concerns raised through Dear David, four concerns raised with the Freedom to Speak up guardian and three concerns raised directly with the CQC. The process behind responding to these concerns was detailed in the paper and the key theme drawn out for the Committee. The Quality Matters e-bulletin continues to be the route for feeding back responses to the concerns raised to staff across the organisation. There had been a noticeable decrease in the number of concerns raised through Dear David however at this stage, it was too early to identify any trends but this continues to be reviewed. The Trust received a rating of ‘Good’ within the Learning from Mistakes League Table published by NHS Improvement earlier in the year. Other areas of acknowledged best practice were also provided to the Committee.

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The Chair commended the work undertaken to promote and improve the routes for staff to raise concerns in particular Dear David.

Quality and Safety Surveillance Report

1.1 The Quality and Safety Surveillance report was presented to the Quality Committee which included the Quality Tile for August 2016. The report is a key source of assurance in relation to quality of care and patient safety and also allowed the Committee to be sighted on any potential risks. The report was being progressed further to allow reporting to be drill down to Networks similar to the Quality Performance Report allowing Networks to consider real time data and escalate early warning signs. Conversations followed around specific areas detailed in the report such as the significant improvement in Friends and Family responses in the Specialist Services Network and the Committee noted the positive work undertaken by the Network which had led to those improvements.

Quality Account 2016/17 1.1 Quality Committee received the Quarter One position of the in-year development of the Quality Account for 2016/17 and the progress made against the Quality Priorities. The Committee noted the non-compliance for Quarter One against the percentage of people who were moving to recovery as a proportion of these who have completed a course of psychological treatment; however changes to practice demonstrates improvements from last year. It was agreed that further detail would come back to the Committee in respect of this.

Quality and Safety Sub-Committee chairs report

1.1, 1.2, 3.1 The Director of Nursing and Quality presented the Quality and Safety Sub-Committee chairs report for the meetings that took place during August and September. The Committee noted the assurances received during the meeting and the additional actions requested to continue to support the mitigation of identified risks. The Committee noted the significant pressures across the organisation in relation staffing and capacity and this was a theme within both reports provided along with a focus on preparing for the CQC re-inspection during August.

Mental Health Law Sub- Committee chairs report

1.1, 7.3 The Director of Nursing and Quality presented the chairs report for the Mental Health Law Sub-Committee held in August. Committee members were reminded that following the annual effectiveness review, all Clinical Directors were now required to attend the meeting along with the chairs of the Network Mental Health Law Groups. The Sub-Committee had requested further evidence around the actions being undertaken to mitigate the risks relating to the Mental Health Act Code of Practice and this continued to be the focus of the agendas. The Chair outlined the discussion that had taken place at Audit Committee in relation to non-compliance with the Mental Health Code of Practice and had commissioned further assurance from the Quality Committee through the Mental Health Law Sub-Committee regarding the Trusts position. The Chair would meet with the Director of Nursing and Quality to discuss this further and agree a format of reporting to the next meeting.

People Sub-Committee chairs report

4.1, 4.2 The HR Director presented the chairs report for People Sub-Committee which highlighted the assurance received in the meeting. The Committees attention was drawn to the positive work being progressed by the Professional Standards Monitoring Group, the Revalidation Steering Group and the Health & Wellbeing Steering Group.

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A discussion followed in relation to compliance with core skills and essential training and the Sub-Committee had requested accelerated assurance around retaining 85% compliance as a minimum and the impact of the developed recovery plans. This would be reported back to the next meeting. Positive progress against the achievements made in the delivery of the People Plan were highlighted to the Committee and People Sub-Committee had supported the formal launch of the Trust’s Coaching Hub.

Never Event – Serious Incident In-depth Review

1.1 Quality Committee received a report following an in-depth review of a serious incident which occurred in November 2015. The incident was classified as a Never Event. The comprehensive report provided background and the care of the service user up to the incident, the Trusts response and action plan developed following the investigation. A discussion took place regarding the procedures which had not been in place at the time of the incident and the lessons learned which had helped formulate the action plan. The delivery of the action plan had continued to be monitored and all actions, with the exception of one had been completed. The Committee requested that Infrastructure Sub-Committee seek assurance against the delivery of the action plan, a review of the window survey as detailed in report and the outcome of the Internal Audit recently undertaken in relation to the Property Services governance arrangements. The Chief Operating Officer agreed to look at the on-call information pack to ensure it was up to date and that a process sat behind it to ensure this was a continual arrangement.

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Board of Directors


Report Title Finance and Performance Committee Chairs Report


Prepared by Ashley Christian, Governance Manager

Presented by Peter Ballard, Trust Deputy Chair

Action required Decision

Supporting Executive Director Chief Finance Officer


Report purpose To provide an outline of the activity undertaken by the Finance & Performance Committee



Board Assurance Framework risk 2.1 The Trust is unable to reposition itself in the marketplace to become established as a provider of choice achieving excellence 2.2 Uncertainty and inconsistency of commissioning arrangements affects the Trust’s ability to address and meet service demands 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability 6.1 The Trust fails to plan, develop and maintain infrastructure to support the ability to deliver safe, responsive and efficient patient care 6.2 The Trust fails to implement the full capabilities of the new EPR which will enable the redesign of service to maximise the clinical benefits to patients and reduce the instances of incomplete patient records

CQC domain Well-led

1.0 INTRODUCTION

This Chairs Report outlines the activity undertaken by the Board level, Finance & Performance Committee held on 4 October 2016.


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CHAIRS REPORT

CHAIRS REPORT OF: Finance & Performance Committee

DATE OF MEETING: 4 October 2016


2.1 The Trust is unable to reposition itself in the marketplace to become established as a provider of choice achieving excellence

2.2 Uncertainty and inconsistency of commissioning arrangements affects the Trust’s ability to address and meet service demands

5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

6.1 The Trust fails to plan, develop and maintain infrastructure to support the ability to deliver safe, responsive and efficient patient care

6.2 The Trust fails to implement the full capabilities of the new EPR which will enable the redesign of service to maximise the clinical benefits to patients and reduce the instances of incomplete patient records

AGENDA ITEMS BAF RISK

DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Action Tracker & Matters Arising

6.2 An overview of the current position of the e-PR case was provided and following the death of the Deputy Medical Director Dr.Gurpal Gossall, a new chief clinical information officer had been identified. The provision of a benefits case was on track and would be in place before the end of December. The additional Finance & Performance Committee and Board meeting to sign off the business case would be December.

Terms of Reference 5.1, 7.1

The updated Terms of Reference for the Committee were endorsed following an update made to highlight that the responsibility to scrutinise financial information remains the responsibility of the Board. The updated Terms of Reference are provided to the Board for approval here. The Terms of Reference for the new Financial Recovery Group were approved by the Committee following a small change to language and can be viewed here.

Finance Sub-Committee & Update on Financial Position

5.1 The Committee received a full update on the financial position and recent telephone conference with NHS Improvement to discuss advice and support regarding the Trust’s recovery plan. A self-assessment would be undertaken to provide assurance the Trust is approaching all elements of the recovery plan as robustly as possible and the update would be provided to the Financial Recovery Group. The recently released planning guidance was discussed in terms of the short deadlines for completing contract negotiations as well as control total and STF funding position for 2017/18. A detailed discussion took place about

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wider provider positioning in the health economy/system and the recognition of the strong targets and ratcheting of control totals. The Trust would ensure every effort goes into preparation of a robust plan but achievement would need to be negotiated in terms of actual delivery.

Infrastructure Sub-Committee

6.1, 6.2

The report included the link between estates/IT and the People Plan and positive feedback was provided about the efforts being made to improve staff experience of IT. Assurance was also provided that risk registers and visibility of content was good but further improvements are continuing. An issue was raised about the estate plans and some concern regarding the delivery of this however a mitigation meeting had been scheduled to escalate and resolve.

Innovation Agency Quarterly Performance Report

2.1 The forecasted performance of the Innovation Agency for quarter 2 was to achieve all milestones subject to completion of additional activity within month 5. The finalised performance report would be circulated to the Committee once completed.

Business Development & Delivery Sub-Committee Chair

2.1, 2.2

Assurance was provided within the Chair report regarding performance around A&E waiting times because the Trust has an instrumental involvement in achievement of waiting times to support acute care. Assurance was also provided that a number of complex patients within PICU have had facilitated transfers which has de-escalated some pressures and will contribute to better flow. The OATs position was confirmed in the meeting at a stable 26 which reflects a small improvement. Operational performance issues identified in the Adult Community network were being closely monitored and work underway to cleanse waiting lists in order to improve waiting times. The monitoring of the prison improvement plan, overseen by NHS England, is continuing whilst issues around workforce and performance levels persist. Dialogue continues to highlight cost pressures and underfunding in the contract with NHS England which have been raised by the Trust. The Committee expect to see the savings from the cease of the prison service support achievement of the control total.

Delivering the Strategy 5.1 Some underperformance was noted within two the DTS programmes however two were on achieving savings which presented a risk around achievement of the control total. Assurance was provided that activity is happening to recover the progress and it was important to recognise that although not fully on track, some savings continue to be made. The gap between the projected savings and actual performance remains largely around bank and agency staff and would form part of the transformational plan for 2017/18.

External Engagement 3.2 Assurance was provided about the activity to maintain relationships with stakeholders, with analysis of data showing positive trend on Twitter. The ‘state of the nation’ updates support understanding of reputation and interactions with elected members and would continue to be reported to the Committee.

Board Assurance Framework

All The Committee reflected on BAF risk 6.1 and agreed that work can begin to downgrade this risk now following the seclusion work and the anticipated CQC report.

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Board of Directors


Report Title Audit Committee Chairs Report


Prepared by Ashley Christian, Corporate Governance Officer

Presented by Louise Dickinson, Chair of Audit Committee




Report purpose To provide an outline of the activity undertaken by the Audit Committee, highlight assurance received and risks identified.



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence.

CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Board level Audit Committee on 11 October 2016.


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CHAIRS REPORT

CHAIRS REPORT OF: Audit Committee

DATE OF MEETING: 11 October 2016


7.1 The Trust does not comply with Monitor Licence and other regulatory requirements under NHS improvements.

7.2 The Trust does not comply with statutory legislative requirements (Excluding Mental Health Legislation which is covered under 7.3)

AGENDA ITEMS BAF RISK DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Committee Reporting 7.1, 7.2 The Committee has requested assurance from both Quality Committee and Mental Health Law sub-committee regarding the non-compliance with some elements of the Mental Health Law highlighted in various reports to the Committee. This is expected at the next meeting.

Corporate Governance & Compliance Sub-Committee Chairs Report

7.1, 7.2 Discussion was had about the more substantial changes brought by the introduction of the Single Oversight Framework; the agency target would now be included within the Trust’s control total and risk ratings had been modified. The impact of these changes will be monitored by Finance sub-committee and also the Financial Recovery Group.

Internal Audit Chair Report

Two internal audit reports were considered CAMHS Transition and Health & Safety Risk Assessments. Although the CAMHS audit provided significant assurance concerns were raised about how quickly some CQC recommendations had been progressed including implementation of the transition protocol. Additional testing will take place on the implementation of recommendations and the Quality Committee would follow up on thetransition protocol as part of its quality and safety remit.

The Health & Safety Risk Assessment provided limited assurance. The audit was commissioned to report on progress to close gaps identified by CQC however gaps still remained at the time of the audit. The Committee has sought assurance that actions had been completed by the September due date and will receive an update once confirmation is available.

Overall, the importance of completing audit actions (including from CQC, clinical audit etc.) in a timely manner was highlighted and this also included follow up of internal audit recommendations from previous years (e.g. bank and agency actions are now overdue and being redefined).

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Anti-Fraud Reporting Assurance was provided that good progress is being made against the plan of work for 2016/17. Work to map sickness absence against bank and agency rates was concluding and would be reported through for the Committee to consider.

External Audit Technical Update

An updated Technical Update which would take account of the planning guidance is expected this month. In the meantime the Committee discussed the potential financial and workforce planning implications from the apprenticeship levy which would be considered at People Sub-Committee and assurance provided to Quality Committee that the organisation is prepared for its introduction. It is recommended that the Board requests an update on this plan.

The ‘Right Staff, Right Skills, Right Place’ publication from the National Quality Board would also be considered at Quality Committee.

The Committee discussed the impact of the NHS conflicts of interest consultation which would inform a further review of the Trust’s Standards of Business Conduct procedure. (The Sunshine Rule)

Clinical Audit Report The Committee considered the detail of the clinical audit findings across the networks and the activity underway to address issues in a range of areas including compliance with mental health law and within the prison service. There were also areas of good practice highlighted as well. It was agreed it was important for the lead manager responsible for each clinical audit to attend the Mental Health Law sub-committee when reports are discussed and this feedback would be incorporated into the reporting process for clinical audits.

Assurance Programme Update

An overview of progress with the assurance directory highlighted how findings from the pilot in Specialist Services had shown management being able to use the directory to identify gaps and improve risk assurance processes. Follow up work with between the network and the Company Secretary is continuing in order to support the network to strengthen its governance arrangements after areas were identified for improvement in the pilot. It was important to ensure risk management and risk assurance reporting is joined-up throughout the governance structure in order to successfully evidence implementation of the governance arrangements within the organisation. A follow up of progress in this area is scheduled for January 2017.

Risk Management & Assurance: Medical

Assurance was provided that there are sufficient governance processes in place within the medical directorate for the management and escalation of risk. This includes those risks identified through clinical audit outcomes and the shared process to triangulate and escalate issues with networks which is in place.

Further consideration would be given to the positioning of pharmacy risks within the Medical Directorate portfolio as it currently sits outside of the reporting structure/escalation process. The Committee commissioned assurance that there were no other risk areas similar to pharmacy which do not directly feed into the risk management and assurance reporting process to Audit Committee and Board.

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Risk Management & Assurance: Workforce

Positive progression in embedding HR risk management processes since the last report to Committee was noted. A refresh of the HR risk register and further implementation of strengthened governance arrangements were key to the improvements. Staff have also undergone training in identifying and articulating risks and a monthly management forum for reviewing risks has been established which also triangulates internal audit actions to ensure timely progression.

Risk Management & Assurance: Specialist Services

The Committee received a contrasting overview of the network’s current risk management arrangements from that previously provided. Although the network continues to embed risk management principles, fast-paced progression to strengthen some new areas identified by the network is needed and a follow up on progress has been scheduled for January 2017. It was confirmed that as part of this, the Governance & Compliance Team were already working with the network to advise on an appropriate governance structure.

Mitigation of Overpayments: HR Controls

Assurance was provided that numbers of new overpayments had reduced, however overall the numbers have only returned to the same position 18 months previous. The next steps in holding individual budget holders and managers to account for overpayments through performance management were discussed and a further follow up in 9 months was agreed to compare year on year performance.

Board Assurance Framework Risks

The risk score of BAF risk 7.1 has the potential to reduce subject to detailed work on the mapping of evidence based assurance against each provider licence condition planned for later in the year. The Committee will receive an update on the provider licence work in January and as part of reviewing the risk, the necessary governance sub-committees will pick up oversight of the clinical licence conditions.

Additional assurance against BAF risk 7.2 will be provided through the corporate policy framework though the compliance reporting element of policies was not yet fully refined but progress would be reported to the Committee in January. It is critical that this work is progressed quickly if the Board is to have adequate assurance that the Trust meets all its legal compliance requirements.

Matters Arising A Non-Executive Director emphasised the need for the Board to have sufficient time scheduled for the refresh of the risk appetite statement which was currently planned for January 2017.

A letter from NHS England was highlighted which notified the Trust of the publication of two independent data security reviews which make recommendations about data security in the health and care system in England. The Chief Finance Officer confirmed that the necessary response to the new security standards would be factored into the IT security report due in January 2017 which will also cover the self-assessment against IS standards.

The MIAA reviews of the prison service and The Harbour will be circulated to the Board and if appropriate, to Audit Committee to consider any specific control issues.

The Medical Director will consider potential quality benchmarking with other high performing mental health and community trusts to inform the organisation’s transformation plans.

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Board of Directors


Report Title LCFT Q2 Workforce Board Report 2016/17


Prepared by Damian Gallagher, Director of Human Resources

Presented by Damian Gallagher, Director of Human Resources




Report purpose To support and inform the Board’s delivery of the LCFT Workforce Strategy


To employ the best people

Board Assurance Framework risk 4.1

CQC domain Well-led

Introduction: The LCFT Workforce Board Report has been designed to provide the Board with a quarterly update on the organisations performance against ten agreed workforce Key Performance Indicators (KPI’s).

The data presented is supported with narrative that highlights the current workforce management challenges being experienced by the Business. The structure of the narrative is designed to provide high level information about the remedial and supportive activities and actions being taken to manage performance improvement and provide assurance to the Board that the organisation is committed to effectively managing and mitigating the identified workforce management risks.

This report provides performance against the workforce indicators for the Quarter 2 period 01 July 2016 to 30 September 2016. The data presented in this report is sourced from the following LCFT Directorates:

Human Resources Finance Quality Academy

Information to support the preparation of narrative is provided by HR Business Partners in conjunction with Network Management.

Members of the Board are invited to note the content of the report and are encouraged to ask any questions and make requests for further information with the Director of Human Resources. The full report can be seen here.

Workforce KPI Performance Headlines: The workforce indicators set out on page 3 of the Workforce Board Report present LCFT’s overall performance against the ten workforce KPI’s in the Quarter 2 period. Performance is rated against the Trusts defined targets, using the Red and Green indicators adopted by LCFT. These are supplemented with an indicative performance trend arrow. The trend is set against performance reported in the previous quarter.

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1. Peripheral Workforce RelianceLCFT’s use of Bank and Agency workforce has reduced in Quarter 2 against the Quarter 1 positionand continues the steady reduction in spend during the 2016/17 operating year.

Acuity of patients, unfilled vacancies and sickness absence are the key reasons identified by theBusiness for the use of peripheral workers. All Networks have targeted improvement plans in eachof these impacting areas and continue to work hard to understand how this element of workforceexpenditure can be more effectively managed whilst managing and maintaining safe operationaldelivery.

2. Operational GapThe operating gap remains below the current Trust target of 5% and LCFT reports a stable closingrate of 2.9%. Maternity & Adoption Leave continues to be the most common absence type in thiscategory.

The total operating gap (including Sickness Absence and Annual Leave absences) is 12.9% at theclose of Quarter 2. This is a slight increase against the Quarter 1 closing percentage of 12.4%.

3. Sickness AbsenceSickness Absence has increased slightly through Quarter 2 and reports a closing rate of 5.99%.In Quarter 2, approximately 53% of the total absences are attributable to Long Term Sickness(Absences lasting 28 days or more in one episode) which is a reduction from the Quarter 1position.

4. Vacancy RateThe board report provides two rates to support the assessment of vacancies.

Establishment Vacancy Rate: The number of vacancies the business runs with against itsBudgeted Establishment

Active Vacancy Rate: The number of vacancies being actively recruited to (this is acount of any vacancy that is within the recruitment process fromrecruitment authorisation through to starting with the trust).

The budgeted establishment vacancy rate has reduced slightly in Quarter 2 against the Quarter 1 position and reports a closing rate of 9.07%.

The Trust continues to focus on proactively and collaboratively managing vacancies and has recently launched a streamlined conversion process for regular Bank Workers to appoint them to permanent employment contracts. ‘Live’ recruitment activity at the close of Quarter 2 reports 402 individual vacancies (totalling 263.29 FTE) across the Trust.

5. Safer Employment Compliance

Core WorkforceCompliance in recruiting and employment, across the Core Workforce, continues to perform well with 100% compliance in Safer Recruitment practice and 98% for Safer Employment practice.

Bank WorkersCompliance within the Bank Only Worker population for Safer Recruitment Practice also continues to perform well and is reporting 100% compliance in Quarter 2.

6. Turnover RateQuarter 2 has seen a slight reduction in the turnover rate, reporting 11.38% at the close of thequarter. This remains above the trust agreed target of 10%.

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7. Appraisal PerformanceQuarter 2 of the 2016/17 performance year presents the second cycle of PDR information andincludes an indicator to demonstrate the number of PDR quarterly reviews that have beencompleted. In addition, two new reporting elements have been included:

A new category of ePDR user has been identified (New Starters) to improve theaccuracy of the Trust compliance and performance rate against PDR processexpectations. A 60 day ‘grace’ period has been agreed for New Starters to complete theePDR process in the new system. The grace period starts from their first day ofemployment.

Medical Workforce Appraisals have been included in Q2 and have facilitated theprovision of a ‘true’ Trust Appraisal compliance rate.

The Quarter 2 Appraisal report uses 4 categories to measure PDR activity and performance against the Trust target:

The proportion of employees who have either: 1. Registered with the new ePDR system and have objectives in place2. Have completed the Medical Workforce Appraisal process.

1. The proportion of New Starters, within the 60 day grace period, who haveregistered with the ePDR system but do not yet have personal objectives in place.

2. Members of the Medical Workforce who have arrangements in place to completetheir Medical Appraisal and are inside the approved timescales for completion.

The proportion of existing employees who have either: 1. Registered with the new ePDR system but have no objectives agreed.2. Have not registered with the ePDR system and for whom we have no information.3. Members of the Medical Workforce who have not completed the Medical Appraisal

process and are outside of their ‘Appraisal birthday’.

The proportion of New Starters, within the 60 day grace period, who have not registered with the ePDR system.

The overall Trust Appraisal compliance rate for Quarter 2 (inclusive of the Medical Workforce) is 68.41%. This represents the number of employees who are either rated Green or Amber, according to the categories above. Although overall compliance remains below the Trust target of 85%, Quarter 2 has seen a significant improvement on the Quarter 1 position and is reflective of the considerable amount of work undertaken by the business to improve the Trust position.

3. Mandatory & Statutory Training ComplianceOverall mandatory and statutory training compliance continues to improve month on month and isreporting an overall compliance of 81.86% at the close of Quarter 2. The People sub-committeecontinues to monitor this target closely and each Network reports improvements in compliance andaccuracy of centrally held compliance data.

4. InductionThe Induction completion rate has continued to perform well, reporting a performance rate of88.3% in Quarter 2.

Damian Gallagher HR Director

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Board of Directors


Report Title Quality and Performance Summary Sheet

FOIA Exemption No Exemption Not Applicable

Prepared by Louise Corlett, Director of Delivery

Presented by Louise Corlett, Director of Delivery


Supporting Executive Director Chief Operating Officer


Report purpose To provide the Board with an overall summary of the Quality Performance Report



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence and other regulatory requirements under NHS Improvements

CQC domain Safe

Board are asked to note the QPR for month 6 with following comments below. The full report can be seen here.

All NHSI indicators were met for Quarter 2, however in month 6 the 95% target for consultant led Referral to treatment (RTT) completed pathways was not achieved. It is worth noting that whilst this indicator is still reported, it is no longer regarded as the constitutional standard for 18 weeks RTT targets. NHS England guidance published in October 2015 confirmed that the 92% RTT incomplete pathway is the measure which indicates compliance with the constitutional standard. The Trust remains compliant against the incomplete pathway measure, albeit on a deteriorating trajectory.

CCG level analysis for consultant led RTT shows breaches to the 95% target in Greater Preston and Chorley South Ribble and reflects patient cancellations of first appointments and an inability of the service to accommodate rearranged appointments within the 18 week timescale due to capacity issues and an extended wait for first appointment.

In relation to other NHS I measures, CCG analysis shows a breach of the 7day FU measure in Fylde and Wyre, Greater Preston and Blackpool CCGs and is reflective of small numbers. For Fylde and Wyre CCG this is the third consecutive month, meriting further investigation by the Network which has confirmed specific mitigation for each case and is not team dependent.

Changes to the QPR format

- Month 5 was the first month where A&E liaison metrics are included in the report. Data collection continues to embed and consequently, whilst all 5 teams have sufficiently robust data

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for inclusion in the QPR report for the 1hr measure, data for other measures continues to require further development and quality assurance.

- In Month 7, Older Adult Mental Health services will transition across to the Adult Mental Health Network and this will be reflected in the QPR report in December.

Adult Mental Health

ADHD – Section 1.1 P36

ADHD continues to underperform against the 18week RTT. The overall % of patients seen within 18 weeks deteriorated this month after the marginal improvement in August. There is, however, a continued (albeit small) improvement in the number of patients waiting over 18 weeks. The service is contracted to focus on transition and the targets are achieved for this group of patients. Referrals from GPs for other patients currently outstrips capacity however a plan to implement leaner ways of working to improve utilisation is in place.

A&E Liaison - Section 1.1 P37

Work to standardise and improve the quality of data capture by the teams went live on the 1st August 2016 and continues. For M6 the contractual measure of 1 hour referral to response by Lancashire Care Mental Health Liaison Teams is reported for all 5 teams. The measures for the following standards are still being developed: 4 Hour A&E Patients referred to response by Mental Health Liaison Team, the 12 Hour A&E Patients referred to Mental Health Liaison Teams, and the 2 Hour Attendance to A&E to referral to Mental Health Liaison Team. The target performance was not achieved and further work is underway to analyse this.

Patient flow – Section 1.2 P70

Patient flow through inpatient beds continues to be challenged. Bed occupancy continues to exceed 100% and episode length of stay has increased in month and is above target (whereas acute length of stay determined from benchmarking is improving). Discharges from PICU beds have resulted in a reduction in PICU length of stay which is positive. Nevertheless, the pressures felt within the inpatient services continue to result in a continued reliance on OAT beds and in turn impact on the Trust’s financial position.

OATS – Section 1.2 P71

OATS were at an average of 29 for September, which is greater than the BBSC plan of 15, although there is an improvement in the OATs occupied bed day usage in month, continuing in October. In September, the effects of the busy August bank holiday weekend continued to be felt. Whilst additional capacity has been opened within the female assessment unit, achieving a balance between demand, staffing, agency usage and OATS reduction remains a key focus for the Network.

Readmission rates – Section 1.2 P75

In M6, both the 30 day readmission rate and the 90 day readmission rate exceeded threshold. This reflects 37 patients being readmitted in 90 days, with 22 of these readmitted within 30 days. Further focus on the initial discharge period through the use of the virtual ward is being implemented to ensure plans post-discharge remain effective to pro-actively prevent readmission.

CCCT – Section 2.2 Contract Activity P108

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As reported previously, the service has been underperforming since the start of 16/17, and at month 6 this remains at -17% YTD. As also reported previously, investigation and remedial work has been undertaken in September to enable data to be refreshed accordingly, this work is still ongoing with data validation required prior to a full refresh.

Contract Activity – Section 2.2 P106

Contract activity is showing 13% over performance YTD across OAMH and AMH. This is mainly due to the contact activity by the Crisis team far exceeding plan, which relates to a historic team mapping issue that has been resolved.

Clustering – Section 1.3 P78

PBR clustering performance has improved to 94.6% against the target of 95% for all patients, with the percentage for those within review being 82%. This represents a sustained improvement for both measures and Network specific actions are in place to improve the position. For the adult mental health network, there is a marked improvement however performance is still below the 95% target at 94%. Clustering champions are being trained to drive further improvements.

Children’s and Families

Child Psychology – Section 1.1 P44

Psychology waits continue to underperform against the 95% RTT standard for complete pathways of care. The M5 position has deteriorated slightly at 67.59% compared to M5. Performance reflects ongoing capacity issues, for which there are plans to address, although the impact of recruitment is not expected to have an impact until early next year. The recovery plan is being refreshed given the slippage to planned compliance.

Contract Activity Section 2.2 P102

Children and Families continue to underperform against the contract activity plan by 7%. Performance below plan relates to Speech and Language therapy and Occupational therapy services. Both services are also reporting underperformance against the 18 week RTT standard of 92% for incomplete pathways. However, M6 sees an improvement against both measures and reflects some improvement in recruitment to vacant posts and skill mix changes.

The current underperformance against the sexual health contract is currently not captured within the QPR. This will be addressed for Month 7 to ensure visibility of performance and the remedial actions to address this.

Adult Community Services

Adult Community are in special measures for finances and operational re CIP and operational control.

Memory Assessment Service (MAS) – Section 1.1 P41

This service remains a key focus for the network because of the significant deterioration in the achievement of the 70% of patients assessed within 6 week standard. In M6 the performance improved only marginally at 37% from 34% in M5. A capacity and demand profile has been established and the key issues to achieving monthly activity are now reported. A forecast trajectory, that can be achieved within the contract value, is being developed.

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Prison Dental – Section 1.1 P39

Dental waits within the prison services continues to be an issue: The position is 93% for the Lancashire prisons against the 18 week target and 85% against the 12 week target in Liverpool and Kennet. This is an improvement for Liverpool and a fairly static position for Lancashire prisons. Performance for all prisons is affected by dental capacity and prisoner availability, which continues to be an issue.

Rheumatology services – Section 1.1 P32

Rheumatology services in month 6 have failed the 95% target for 18 weeks RTT for completed pathways. The 92% RTT incomplete pathway target has been achieved but continues to deteriorate. This is matched with an over- performance in activity against contract of 13% and continues to reflect the increased demand that is not currently matched with available capacity. The position is being closely monitored as it expected that the 92% measure may be jeopardised if capacity cannot meet demand. A refreshed business case is being discussed with commissioners in November with a view to increasing capacity.

Community Contract – Section 2.2 P93

Overall the community contract is 9% above plan in month 6. Greater Preston CCG is down -3.5% against plan, balanced with significant over performance in other CCGs. Commissioners have requested a deep dive into 6 areas to understand current performance: District nursing, community matrons, speech and language therapy, community respiratory, domiciliary physio and community learning disabilities.

Specialist Services Contract

We have significant performance improvements to deliver in each of the prisons and the specifics continue to be managed via the weekly special measures meeting and weekly SITREPs.

A decision was taken not to bid for the 5 Lancashire prisons and we await notice of the outcome of the tender. In the meantime, the network focus on business continuity and challenges around performance are expected to continue to be a focus.

A review of indicators reported within the QPR is being undertaken to align to contract and to set internal targets that are comparable to other providers.

All Networks

All areas continue to report significant vacancies and the Adult Mental Health Network and the Specialist Services Network have vacancy rates greater than the Trust average and relatively low percentages of active recruitment. This correlates to the greater level of reliance on temporary staffing and spend compared to other Networks. The turnover rate is largely static and work is underway to understand the impact of inter-Trust transfers.

The focus on e-rostering continues in Networks and this is being fully supported via Director of Nursing and corporate nursing team. This is important given the context around vacancy rates, high occupancy levels, delivering new models of care and the need to reduce expenditure on temporary staffing whilst maintaining safety. This continues to be challenging for all Networks in the current climate.

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Board of Directors


Report Title Finance Report – Month 6

FOIA Exemption Part Exemption Section 41: Information provided in Confidence

Prepared by Dominic McKenna – Financial Management Director

Presented by Bill Gregory – Chief Finance Officer


Supporting Executive Director Chief Finance Officer


Report purpose To summarise and analyse actual and forecast financial performance and standing of the Trust, the implications and any proposed management action


To provide excellent value for money in a financially sustainable way

Board Assurance Framework risk 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

CQC domain Effective

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Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 1 4,263 6,646 ‐2,383 1 13,065 13,257 ‐192 Operational Deficit 1 ‐3,113 ‐696 ‐2,417 1 ‐1,381 ‐1,390 9

CIPs (against Trust Plan) 3 5,535 5,728 ‐193 3 12,286 12,286 0Cash and Liquidity 3 10,651 14,490 ‐3,839 3 13,302 11,561 1,741Capex 3 2,042 5,000 ‐2,958 3 7,999 7,999 0FSRR

Capital Service 1 1 2 1 2 2Liquidity 5 4 3 3 4 3I&E Margin 1 1 2 1 2 2I&E Variance 1 2 3 2 3 3Overall 1 2 3 2 3 3

Sustainability

Liquidity

Capital and Financing

Financial Sustainability Risk rating (FSRR)

Key Actions

#• Maintain focus on OATs and delivery of mitigations.

Overall the draft FSRR is rated at 2 against plan of 3 primarily as a result of the I&E position. The rating is also constrained by both Surplus Margin and Debt Service rating which are rated at 1 ‐ any score of 1 limits score to 2.Should conditions persist and costs not be managed within the control total then the resulting deterioration might attract regulatory attention (a rating of 2 can trigger a regulatory review of the Trust's position).

The Trust has made progress on the programme in line with revised forecasts and expectations (Month 6 £2.0m, Month 5 £1.7m) with forecasts now including a saving of £2m against the original plan to support cash mitigation plans. The Trust has now been informed that a Capital Control Total (CCT) will not be introduced in 2016/17, but continues to anticipate a CCT for 17/18.

Note that the Single Oversight Framework has now been published and that from October the Trust will be managed against the Use of Resource Metrics (UoR). Indicative scores have been provided for both YTD and forecast positions.

• Key focus on delivering the Recovery Plan.

• Maintain focus on delivery of CIPs and increase focus on stretch targets.• Increase focus on addressing Ward Staffing ,particularly in Adult Mental Health.

Current Out‐Turn

Month 6 sees a year to date operating deficit of ‐£3.1m (Month 5 ‐£2.7m), £2.4m behind plan for the year. £1.0m relates to Sustainability and Transformation funding which can be recovered when the Trust achieves its financial targets. It is projected that the full year operating deficit after mitigations would be £1.4m, but this is not without risk and without mitigation the Trust is in line for a £7.9m overspend ‐ note that this is a deterioration of c£0.7m on month 5, details in the Forecasting section. The month to month position also shows some deterioration – month 6 ‐£0.46m (month 5 ‐£0.30 month 4 ‐£0.44m, month 3 ‐£0.62m), primarily as a result of the 5 week month impact on temporary staffing and deteriorations in the Community and Children's & Families networks; overspends in ward areas remain an issue as do risks around OATs (further details in the OATs section). The Board Balanced Scorecard demonstrates an EBITDA (earnings before interest, taxes, depreciation and amortisation) of £4.3m against a plan of £6.6m. FSRR is rated at 2, but will rise to a 3 should the Trust meet its financial plans and targets, see below.

Cash shows a significant reduction from last month (£5.3m), primarily due to the Loan and PDC Repayments (£4.1m). Cash is similar to last month after taking into account repayment of Loan and PDC. See Cash and Liquidity for more details.

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Forecast ForecastYTD YTD Out‐turn Out‐turn

Sep 2016 Aug 2016 at Sep 2016 at Aug 20166 5 Note 12 12 Note

Plan ‐0.696 ‐0.580 Plan ‐1.390 ‐1.390

Major Variances Major VariancesCIP Slippage ‐0.193 ‐0.273 ‐ See CIP section CIP Slippage 0.000 0.000 ‐ See CIP sectionOATs 0.000 0.000 ‐ See OATs section OATs ‐0.421 ‐0.318 ‐ See OATs sectionStaffing ‐4.114 ‐3.305 ‐ See also Bank and Agency section Staffing 4.320 4.740 ‐ See also Bank and Agency sectionOther Bud Vars ‐0.117 ‐0.359 ‐ See Services section Other Bud Vars ‐6.859 ‐8.648 ‐ See Services sectionReserves 2.007 1.865 ‐ See Reserves section Reserves 2.169 3.527 ‐ See Reserves sectionAddl SS Activity ‐0.001 ‐0.001 ‐ Addl SS Activity 0.800 0.700Minor Variances 0.000 0.000 Minor Variances 0.000 0.000

Variance ‐2.417 ‐2.072 Variance 0.009 0.000

Actual ‐3.113 ‐2.652 Actual Forecast ‐1.381 ‐1.390

‐‐

Surplus ‐ YTD (£m) Surplus ‐ Out‐turn (£m)

This month sees an operating deficit of £3.1m, £2.4m behind plan, of which £1.0m is STF funding not yet accrued.The full year projection is an operating deficit of £1.4m, accounting for the STF funding in the plan. The position models the mitigations included in the recovery plan (£5.8m) and includes provision £1.6m for OATs costs.

‐5,000.0

‐4,000.0

‐3,000.0

‐2,000.0

‐1,000.0

0.0

1,000.0

2,000.0

3,000.0

Plan CIP Surplus OATs Staffing Other BudVars

Reserves Addl Income MinorVariances

‐1,390.0 0.0 ‐421.0 4,319.7 ‐6,858.7 2,168.6 800.0 0.0

‐6,000.0

‐5,000.0

‐4,000.0

‐3,000.0

‐2,000.0

‐1,000.0

0.0

Plan CIP Shortfall OATs Staffing Other BudVars

Reserves STF Funding MinorVariances

‐696.0 ‐193.0 0.0 ‐4,114.0 ‐116.7 2,007.5 ‐1.005 0.0

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Plan 166.053 138.419 Plan 333.286 333.286

Major Variances Major VariancesCommunity Services 0.686 0.704 ‐ Note 1 Community Services ‐0.270 ‐0.801 ‐ Note 1Mental Health 3.821 2.899 ‐ Note 2 Mental Health 5.600 4.681 ‐ Note 2Specialist Services 0.068 0.090 ‐ Note 3 Specialist Services 0.078 0.078 ‐ Note 3Non NHS Healthcare In ‐1.317 ‐1.050 ‐ Note 4 Non NHS Healthcare In ‐2.717 ‐2.369 ‐ Note 4R&D ‐0.071 ‐0.053 R&D ‐0.106 ‐0.142ETR 0.432 0.428 ‐ Student Income ETR 0.760 0.726 ‐ Student IncomeMiscellaneous 0.952 0.278 ‐ Note 5 Miscellaneous 2.413 1.098 ‐ Note 5

Minor Variances 0.000 0.000 Minor Variances 0.000 0.000

Variance 4.570 3.296 Variance 5.759 3.271

Actual 170.623 141.715 Actual Forecast 339.045 336.557

1

2345 Major increases in respect of AHSN, IT and Test Bed funding ‐ see appendix for detailed impact.

Monthly Income Variances (£m) Cumulative Income Variances (£m)

Major decrease is due to the confirmation that the Community Equipment Service (CERS) will demise, realising a reduction of over £2.4m in year. Both CERS and Longridge Hospital funding contribute to year to date increase.Major increases include contractual settlement reached re CCGs, CAMHS, Early Intervention, Resilience and Acute Therapy Service funding.Minor increase is in respect of funding for additional activity and increased acuity.Major decrease expected is respect of Healthier Lifestyles contracts, changes to inflation and sexual health.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

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

Actual/Forecast

Plan

0.000

50.000

100.000

150.000

200.000

250.000

300.000

350.000

400.000


Actual/Forecast

Plan

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Budget 146.138 122.183 Budget 287.880 288.080

Major Variances Major VariancesAdult Mental Health ‐3.013 ‐2.026 ‐ Note 1 Adult Mental Health ‐2.656 ‐2.625 ‐ Note 1Specialist Services ‐2.070 ‐2.015 ‐ Note 2 Specialist Services ‐2.102 ‐2.107 ‐ Note 2Property Services 0.000 0.000 ‐ Note 3 Property Services 0.000 0.009 ‐ Note 3Corporate 0.832 0.318 ‐ Note 4 Corporate 1.445 0.912 ‐ Note 4Adult Community ‐0.616 ‐0.658 ‐ Note 5 Adult Community ‐0.110 ‐1.020 ‐ Note 5Children & Family 0.219 0.254 ‐ Note 6 Children & Family 0.172 0.372 ‐ Note 6Other Clinical 0.224 0.189 Other Clinical 0.289 0.233

Variance ‐4.424 ‐3.937 ‐2.960 ‐4.226

Actual 150.562 126.120 Actual Forecast 290.840 292.307

1

2

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56 Children and Families in month and outturn position has deteriorated due to reduced sexual health activity (c£425k) in part offset by reductions in spend in CAMHS, Universal and CITNS.

Adult Mental Health in year overspend is driven more acutely by excess staffing costs on wards. Actions to review the patients in inpatients setting, their appropriateness for the ward and levels of staffing associated with acuity are advanced and should furnish us with the appropriate information to discuss necessary action with the respective commissioners. There is some CIP slippage, and an assumption of a £400k overspend on OATS.Specialist Services are behind plan driven by high use of bank & agency on wards, particularly in male Medium Secure Services, where high levels of acuity are having to be dealt with and patients who should be in High Secure placements. Additionally, Prison services have struggled to recruit permanent staff and have therefore experienced high levels of agency staff and the associated cost pressures. The impact of the Kennet Prison closure is still being discussed. Expenditure has stabilised.Property Services are operating in line with plan.

YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)

Corporate Services forecast are contributing underspends, most significantly with regard to mental health drugs (in Medical Director) where year to date underspends of £0.3m and full year underspends of £0.6m are being returned. Most other areas are also returning underspends both in year and full year, driven by cost control and vacancies, however Human Resources continues to overspend (£0.1m full year), but IT is delivering significant underspends on both pay and non‐pay.Adult Community's position is also compromised by temporary staffing is ward areas, but is now reporting a significantly improved outturn.

‐£3,500‐£3,000‐£2,500‐£2,000‐£1,500‐£1,000‐£500

£0£500

£1,000£1,500£2,000

Adult MentalHealth

SpecialistServices

PropertyServices Corporate

AdultCommunityServices

Children &Family Other Clinical Total

Service Forecast Variance

‐£5,000

‐£4,000

‐£3,000

‐£2,000

‐£1,000

£0

£1,000

£2,000

Adult MentalHealth

SpecialistServices

PropertyServices Corporate

AdultCommunityServices

Children &Family Other Clinical Total

Service Year to Date Variance

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CIP Achievement (£)

NotesYear to Date PerformancePerformance against monitored and approved schemes is £193k behind plan. The Rehab Gateway scheme is not delivering against plan, however an invoice to BwD CCG has been raised for £513k. The Monitor Agency Cap scheme is £80k ahead of plan.

Schemes to be TransactedThough transacted schemes are currently ahead of plan, the outturn remains contingent on schemes in process being transacted as planned.Additional schemes continue to be identified and will be transacted when fully developed.

Transaction PhasingScheme plan phasing is ahead of the plan submitted to NHSI.

Changes from forecastSchemes are currently expected to exceed Annual Plan ‐ Annual Plan is £12.3m and the target is £16m ‐ potential improvements have been prudently excluded from forecasts.

Note mapping of individual schemes to projects and programmes may be subject to change.

Delivering the Strategy ‐ 2016/17 PROGRAMMES

Programme No.

Programmes Project Ref ProjectsActual YTD Performance Plan YTD Var Annual Performance Annual Plan Var

T01A Central Lancashire Existing Business 235,136 235,136 ‐ 511,771 511,771 ‐T01B CEHWB ‐ Tier 3 & 4 CAMHS 79,953 79,953 ‐ 159,906 159,906 ‐

T01CSkype/telemedicine/telehealth implementation incl. Test Beds (Trust wide)

50,000 50,000 ‐ 150,000 150,000 ‐

T02A B&A Efficiency (Trust Wide) ‐ ‐ ‐ ‐ ‐ ‐T02B Admin Optimisation (Trust Wide) 217,624 217,624 ‐ 435,247 435,247 ‐

T02CConsultant Job Planning and rota efficiency (trust wide)

73,541 73,541 ‐ 147,082 147,082 ‐

T03A Specialist rehab gateway ‐ 376,500 376,500‐ ‐ 753,000 753,000‐T03B Medicines optimisation and ePMA 129,000 129,000 ‐ 258,000 258,000 ‐T03C Prison Health Redesign 50,000 50,000 ‐ 100,000 100,000 ‐T03D Liaison and Diversion Criminal Justice 99,462 99,462 ‐ 198,924 198,924 ‐T04A Monitor agency cap 311,286 231,221 80,065 418,903 400,000 18,903T04B MARS 244,444 244,444 ‐ 611,109 611,109 ‐T04C Direct Engagement Model 127,072 119,639 7,433 248,552 250,000 1,448‐T04D Finance ‐ Commissioning and Contracts 1,315,000 1,315,000 ‐ 2,630,000 2,630,000 ‐T04E Procurement Incl nurse and benefit realisation 7,250 7,250 ‐ 14,500 14,500 ‐T04F Estates ‐ Site rationalisation and efficiencies 553,008 553,008 ‐ 1,106,016 1,106,016 ‐T04G Corporate overarching ‐ Travel savings 248,404 248,404 ‐ 496,807 496,807 ‐

T04HCorporate overarching ‐ Corporate services business plans

578,955 578,955 ‐ 1,157,909 1,157,909 ‐

T04I Corporate overarching ‐ Network business plans 1,214,748 1,214,748 ‐ 2,328,084 2,328,084 ‐T04J Corporate overarching ‐ Network redesign ‐ ‐ ‐ ‐ ‐ ‐

5,534,880 5,823,882 289,002‐ 10,972,810 11,708,355 735,545‐

Schemes not yet transacted within the PMG ‐ 1,314,190 578,645 735,545

Transaction phasing 95,882‐ 95,882 ‐

Forecast Outturn 5,534,880 5,728,000 193,120‐ 12,287,000 12,287,000 0‐

2 Excellence in Patient Flow

1 Prevention and Community Wellbeing

4 Corporate Services

3 Specialist Services

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Month Month Month MonthSep 2016 Aug 2016 Sep 2016 Aug 2016

6 5 Note 6 5 Note

Agency Spend 1,133 986 Bank Spend 1,570 1,238

Network Analysis Network AnalysisAdult Network 620 449 ‐ Note 2 Adult Network 872 720 ‐ Note 2Adult Community 182 177 ‐ Note 3 Adult Community 189 154 ‐ Note 3Children & Families 91 106 ‐ Note 4 Children & Families 63 30 ‐ Note 4Specialist Services 287 270 ‐ Note 5 Specialist Services 378 304 ‐ Note 5Corporate Services ‐46 ‐16 ‐ Note 6 Corporate Services 67 30 ‐ Note 6

Actual 1,133 986 ‐ Note 1 Actual 1,570 1,238 ‐ Note 1

12

3

45

The Trust has been given a ceiling by NHS Improvement for agency spend. This target is £7.695m for the year. At the end of period 6, the Trust is £2.3m, or 53% above it's trajectory. Failure to hit the ceiling could invite intervention by NHSI.

A high level of vacancies is supported by bank and agency, total staffing deployed is well above establishment but is moving in a positive direction.Adult Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established. The position has deteriorated this month in both bank and agency, in part due to September being a five week month. Adult Community bank and agency costs are driven by acuity in Older Adult services. Several reviews are in place with a view to reducing temporary staffing, with particular emphasis on agency reduction, which has continued to see an improvement. Again, the five week month has impacted.Expenditure is fairly minor within Children and Families, with changes delivering an improved position on agency but a deterioration in bank.Specialist Services Network bank and agency costs are partly due to the contract for Liverpool and Kennet Prisons and partly to acuity on inpatient wards. Positions are being recruited to but getting staff in post is problematic. Measures have been put in place to improve internal temporary staffing controls.

Agency Costs Over Time (£'000) Bank Costs Over Time (£'000)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2014/15 1102 1004 1070 996 1108 1089 1063 1141 1015 899 988 11812015/16 935 1108 932 1180 1119 1176 1139 1183 1170 1072 1289 12092016/17 1536 1521 1728 1390 1238 1570

0200400600800

100012001400160018002000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2014/15 1050 929 928 1254 1250 1146 1125 939 1248 1146 1050 12542015/16 1030 988 1262 1242 909 1202 1149 939 1073 1077 978 11742016/17 1098 862 1250 1184 986 1133

0

200

400

600

800

1000

1200

1400

Agency Ceiling Apr May Jun Jul Aug Sep Total Projection

Actual 1,098 862 1,250 1,184 986 1,133 6,513 10,577Plan 927 827 727 625 575 575 4,256 7,695Variance ‐171 ‐35 ‐524 ‐559 ‐411 ‐558 ‐2,257 ‐2,882% of Plan ‐53% ‐37%

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Month Month YTD ForecastSep 2016 Aug 2016 Sep 2016 Out‐turn

6 5 Note 6 12 Note

Plan ‐4.1 0.2 Plan 14.5 11.6Major Variances Major Variances

I&E ‐0.3 ‐0.2 ‐ Note 2 I&E ‐2.4 ‐0.2 ‐ Note 2Capital & financing 0.4 0.4 ‐ Note 2 Capital & financing 2.6 1.7 ‐ Note 2Contract Vars and Adjs ‐0.1 ‐0.2 Contract Vars and Adjs ‐1.8Debtors ‐1.5 2.3 ‐ Note 3 Debtors ‐2.9 ‐1.8 ‐ Note 3Timing of settlements to suppliers 0.4 0.4 ‐ Note 4

Timing of settlements to suppliers ‐2.4 0.1 ‐ Note 4

Provisions and deferred income ‐0.1 ‐0.1 ‐ Note 5

Provisions and deferred income 1.6 0.5 ‐ Note 5

Opening cash 0.0 0.0 Opening adjustment 1.5 1.5

Minor Variances 0.1 0.0 Minor Variances 0.0 0.0

Variance ‐1.2 2.7 Variance ‐3.8 1.7

Actual ‐5.3 2.9 Note 1 ForecastActual/Forecast 10.7 13.3 ‐ Note 1

1

2

3

4

5 Provisions and Deferred Income are currently generating gains of £1.6m over plan, a combination of unreleased MARS and redundancy provisions and higher than anticipated levels of deferred income. Future MARS and Redundancy settlements will reduce this gain.

Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)

Timing of settlements to suppliers again shows some improvement (c£0.4m) though, as with last month, but remains behind plan (c£2.4m) due to low levels of both accrued expenditure and recharges.

Reductions in capital expenditure are supporting cash compensating to some degree for the accumulating impact of the deficit. This is expect to continue, however, potential forecast mitigation is limited to c£2m. Debtors are slightly higher than plan (c£2.9m), c£2.1m relates to the timing of council payments with the remainder being largely due to OATs (£1m). Council debt remains high on the agenda.

Cash is currently £3.8m behind plan, partly as a result of the impact of the deficit position but mainly as a result of transient issues around working capital (see below). The current year end forecast assumes that proposed management action to bring financial performance back in to line is achieved and also that the Trust, as a result, maintains eligibility for Sustainability Funding. It also assumes capex reductions and that high debtors persist.

Cash shows a significant reduction from last month (£5.3m), primarily due to the Loan and PDC Repayments (£4.1m). Though cash remains behind plan it distance from plan is broadly similar to last month (month 6 £3.8 month 5 £2.6m , month 4 £5.3m).

‐8.000

‐6.000

‐4.000

‐2.000

0.000

2.000

4.000

6.000


Opening cash balance

Financing and Other

Capital and Investment Activities

Changes to WC

Non Cash Flows

Surplus/(deficit) after tax

0.000

5.000

10.000

15.000

20.000

25.000


Forecast

Plan

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YTD Forecast YTD Act Annual ForecastSep 2016 Sep 2016 Variance Plan Out‐turn Variance£000 £000 £000 £000 £000 £000

IT Schemes 0.118 0.118 0.000 3.600 2.600 ‐1.000 ‐ Note 1

Estate and infrastructure SchemesPrecommitments 1.347 1.347 0.000 1.612 1.833 0.221 ‐ Note 2

Large Schemes 0.192 0.192 0.000 1.600 1.810 0.210 ‐ Note 3

High Priority Schemes 0.018 0.018 0.000 1.051 0.668 ‐0.384 ‐ Note 4

Backlog maintenance 0.167 0.167 0.000 0.330 0.337 0.007General 0.199 0.199 0.000 1.807 0.752 ‐1.054 ‐ Note 5

Total 2.042 2.042 0.000 10.000 8.000 ‐2.000

1

23

4

5

Capital Expenditure

The Trust has made progress on the programme in line with revised forecasts and expectations (Month 6 £2.0m, Month 5 £1.7m) with forecasts now including a saving of £2m against the original plan to support cash mitigation plans.

The Trust has now been informed that a Capital Control Total (CCT) will not be introduced in 2016/17, but continues to anticipate a CCT for 17/18.

Timing of the procurement of EPR has resulted in slippage against original plan, this coupled with other savings has enabled It to forecast a saving against the original plan of c£1m to support Cash Mitigations. Slippage has now largely been caught up, with Ridge Lea scheme now complete.Main variance is in relation to Ward 22 and is largely due to project redesign. The project has now been reprofiled and enabling works commenced, it is still expected to be completed within the year.Planning assumptions have now been reviewed with several schemes being reprofiled. The schedule now anticipates the delivery of c£1m savings to support cash mitigation plans.Expenditure is behind plan but is expected to deliver against the revised forecast.

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Actual/Forecast represents weighted averageOverride represents Actual/Forecast Rating

YTD Forecast YTD Forecast YTD Forecast YTD Forecast YTD ForecastSep 2016 Out‐turn Sep 2016 Out‐turn Sep 2016 Out‐turn Sep 2016 Out‐turn Sep 2016 Out‐turn

6 12 6 12 6 12 6 12 6 12

Plan 3 3 Plan 2 2 Plan 3 3 Plan 2 2 Plan 3 3

Actual/Forecast 2 3 Actual/Forecast 1 2 * Actual/Forecast 4 4 Actual/Forecast 1 2 * Actual/Forecast 2 3

*Scoring a 1 on any metric will cap the weighted rating to 2, potentially leading to investigation.

Key Points

‐

‐ ‐ ‐

‐

Surplus Margin rating is currently 1 against a plan of 2, an increase in operating performance of c£1.4m would be required to increase the rating to 2 ‐ Note that the deficit of ‐£3.1m is 2.4m behind plan (£1.4m behind the RCT).Variance from Plan is currently 2 against a plan of 3, an increase in operating performance of c£0.8m would be required to increase the rating to 3.

FINANCIAL SUSTAINABILITY RISK RATINGS

Assuming the proposed management action to bring financial performance back in to line is achieved the Trust will maintain eligibility for Sustainability Funding and will achieve an FSRR of 3 in line with the revised plan.Should conditions persist and costs not be managed within the control total then the resulting deterioration might attract regulatory attention (a rating of 2 can trigger a regulatory review of the Trust's position).Capital Service is currently a 1 against a plan of 2, with the recent repayments of loans and PDC an increase in operating performance of c£1.6m would be required to increase the rating to 2.Liquidity is currently a 4 against a plan of 4, a deterioration in the liquidity metric of c£2.1m would be required to reduce the rating to 3.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Apr‐15 Jul‐15 Oct‐15 Jan‐16

FSRR ‐ Overall

Actual/Forecast Plan

0.0

0.5

1.0

1.5

2.0

2.5

3.0


FSRR ‐ Capital Service

Actual/Forecast 4 3 2 1

‐15.0

‐10.0

‐5.0

0.0

5.0

10.0


FSRR ‐ Liquidity


‐2.50%

‐2.00%

‐1.50%

‐1.00%

‐0.50%

0.00%

0.50%


FSRR ‐ Variance from Plan


‐2.5%‐2.0%‐1.5%‐1.0%‐0.5%0.0%0.5%1.0%1.5%


FSRR ‐ Surplus Margin


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Use Of Resource Metric

unitsPlan

YTD ending 30-Sep-16

Actual YTD ending 30-Sep-16

Variance YTD ending 30-Sep-16

Plan Year ending 31-Mar-17

Adjusted Forecast

Year ending31-Mar-17

Forecast Variance

Year ending31-Mar-17

Threshold 1 2 3 4

Capital Service Cover 2.5 1.75 1.25 <1.25Capital Service Cover Liquidity 0 -7 -14 <-14

I&E Margin 1.00% 0.00% -1.00% <=-1%Capital service metric 0.0x 1.437 0.921 (0.517) 1.436 1.416 (0.020) Variance from plan 0.00% -1.00% -2.00% <=-2%Capital service rating Rating 3 4 3 3 Agency 0.00% 25.00% 50.00% >=50%

Liquidity

Liquidity metric £m (0.147) 2.242 2.389 (2.855) 0.770 3.625Liquidity rating Rating 2 1 2 1

I&E MarginMetric Weighting

I&E Margin metric % (0.42%) (1.83%) (1.42%) (0.42%) (0.41%) 0.00% Capital Service Cover rating 20.00%I&E Margin rating Rating 3 4 3 3 Liquidity rating 20.00%

I&E Margin rating 20.00%I&E Variance From Plan Variance From Plan rating 20.00%

Agency Spend 20.00%I&E Variance from plan metric % (1.42%) 0.01%I&E Variance from plan rating Rating 3 1

Agency

Agency metric % 0.00% 53.03% 53.03% 0.00% 37.45% 37.44%Agency rating Rating 2 4 2 3

Use Of Resources Rating

Overall rating unrounded Rating 3.20 2.20If unrounded score ends in 0.5 Rating - -Rounded score Rating 3 2

Use Of Resources Rating before overrides Rating 3 2

4 Rating Trigger for Use Of Resources Rating Text TRIGGER NO TRIGGER

Use Of Resources Rating after 4 rating override Rating 3 2

Control total override - Control total accepted Text Yes Yes

Is the provider in Financial Special Measures? Text No No

Use Of Resources Rating after overrides Rating 3 2

Finance and use of resources is one theme of 5 in the Single Oversight Framework. Segmentation and therefore autonomy and support is dependent on performance across all themes.

Note that under the Single Oversight Framework a score of 1 is now the best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.

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Reserves

Annual statement of Revenue Reserves

Budget Charge VariancePay Reserve 1,240 330 910 Assumed calls on funds to the end of the year.Non Pay Reserve 416 ‐972 1,388 Funds as yet unutilised, plus gains on year end redundancy and other provisionsPressures Reserve 935 670 265 Funds to be allocated by year endOATS Provision 0 1,380 ‐1,380 Additional Provision for c20 bedsMARS Gain ‐135 ‐135 0 In year savings from MARS schemeCIP Reserve 705 ‐440 1,145 This represents the CIP schemes yet to be transacted, and assumed overachievementAgency Cost Savings ‐900 ‐883 ‐17 In year savings from Medical and clinical staff caps

2,262 ‐50 2,312

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` MATTERS

ID Meeting DatPaper Status

2016/09 Sep-16 Matters Excluded

2016/07 Jul-16 Matters Partial

2016/08 Jun-16 Matters Excluded

2016/01 May-16 Matters Included



2016/04 May-16 Matters Excluded

2016/05 May-16 Matters Excluded

02/08 May-14 MattersExcluded

NHSE have formally given notice on the cessation of the prison services at Kennet. Financial implications are being assessed anddiscussions with commissioners are being progressed. Commissioners have indicated a changed closure date.

NHS Improvement have yet to issue the anticipated Capital Control Total.

The Trust is actively exploring the potential for land sales. Gains may crystallise in 16/17 dependent on timing.

Subject

On-going Claims- Speculative VAT claims continue to be pursued in relation to older developments and changes in rulings. A recent ruling now

supports our claim, but the claim is by no means certain to succeed. Up to £2m no gain assumed.

While the service remain confident of managing OATs, they are calculating a figure of £4.4m above the £4m envelope.

The contract with SpecCom is now signed.

The Trust has met LCC and is hopeful a way forward has been agreed but major contracts remain unsigned.

The Trust has been granted c£2m from the Sustainability and Transformation fund, this has now been included in the month 3accounts process. NHS Improvement have now published the new "Single Oversight Framework", a paper will be produced for the next FinanceCommittee.

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OUT OF AREA ACTIVITY

Apr‐16 May‐16 Jun‐16 Jul‐16 Aug‐16 Sep‐16 Oct‐16 Nov‐16 Dec‐16 Jan‐17 Feb‐17 Mar‐17 TotalCurrent Forecast £ 440 710 740 730 602 504 242 90 93 93 84 93 4,421

Charge to LCFT 440 560 0 620 380 0 151 93 84 93 2,421Charge to Commissioners 150 740 110 222 504 242 90 ‐58 2,000Variance 0 0 0 0 0 0 0 0 151 93 84 93 421Cumulative Variance 0 0 0 0 0 0 0 0 151 244 328 421

12

34

5

Work is advanced in identifying patients within PICU capacity (both Trust and OATS) who should be covered by non‐Lancashire CCG contracts and this additional activity will form the basis of discussions with the relevant commissioners.

The Network has developed a trajectory against which we are monitoring performance. The forecast assumes slight delays in opening assessment beds.

Commissioners have asked for, and are receiving, monthly actual performance against the profile.

The Trust provided £2m for OATs, which was the level deemed affordable at planning and not intended to remove all risk. Commissioners matched this to give a funding envelope of £4m. The £2m contribution from CCGs must be considered their maximum liability.

FOIA Exempt under Section 43 Commercial Sensitivity.

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Board Of Directors


Report Title Board Assurance Framework Update for Q2

FOIA Exemption Part Exemption

Prepared by Julie-Ann Bowden, Associate Director of Compliance and Business Assurance

Presented by Julie-Ann Bowden, Associate Director of Compliance and Business Assurance

Action required Decision



Report purpose To provide assurance in relation to the Q2 review of the BAF risks. To provide an update in relation to the risk appetite statement review process.



Board Assurance Framework risk This report contains an update relating to all 2016/17 BAF risks

CQC domain Well-led

PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date

All sub-committees and committees within the governance framework over the course of Q2 have reviewed relevant BAF risks and 15 and above risks

NA NA NA

EMT Julie-Ann Bowden Discussion 17.10.16

Network Risk Forum Julie-Ann Bowden Discussion 08.07.16

Combined Risk Forum Julie-Ann Bowden Discussion 02.09.16 & 11.10.16

1.0 INTRODUCTION 1.1 The Board of Directors has overall responsibility for ensuring that systems and controls are in

place that are adequate to mitigate any significant strategic risks which threaten the achievement of the strategic objectives.

1.2 The strengthened management processes around the analysis and evaluation of risk which compliments the governance arrangements, continues to support more detailed analysis, which has provided Executive Management Team with an opportunity to look at the aggregation of risk from a management perspective and examine the impact on the strategic priorities of the organisation.

1.3 As part of the end of Q2 process the Board Assurance Framework (BAF) has been reviewed in detail with each risk owner. The review has considered: The need to review the strategic objectives against the key risk areas to reflect the outputs

from the strategic planning process.

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The need to consider the re-scoring of the BAF risks taking account of an assessment ofthe assurances and controls and any gaps identified during Q2. This takes particularaccount of assurances delivered through the governance meetings and information in theChairs’ Reports.

Work to strengthen the analysis of mitigating actions required to close the gap between thecurrent risk score and the target risk score.

Ensuring that systems and controls are in place that are adequate to mitigate anysignificant strategic risks which threaten the achievement of the strategic objectives.

1.4 The report provides an opportunity for the Board to review the position for 2015/16 BAF risk register at the end of the Q2 position.

2.0 DEVELOPMENT OF THE MANAGEMENT RISK FORUMS 2.1 The combined Risk Forum has met twice during the reporting period and has provided

opportunity to review risks by theme across the organisation. In addition, Networks and Support Services have brought risks for discussion where there is a need for more collaboration across the organisation to manage these risks. At the meeting held on 11 October 2016, Children and Families Network raised a number of risks relating to medical workforce. This was also a theme across other areas. The Chief Operating Officer proposed that a piece of work was undertaken outside the Risk Forum and reported back to the next meeting to assess the level of risk exposure across the Trust which ties in with a report due to EMT at the end of October in relation to medical staffing retention and recruitment which is being led by the Deputy Medical Director.

3.0 REVIEW OF THE BOARD ASSURANCE FRAMEWORK (BAF) STRATEGIC RISK

REGISTER

3.1 The quarterly review process provides an opportunity for Executive Director leads to meet with the Associate Director of Compliance and Assurance to discuss the update of their relevant risks. All these meetings have taken place and adjustment to the BAF risks has been undertaken. The BAF risks with associated 15 and above risks can be viewed in Appendix 1

3.2 The Heat Maps for the year to date can be reviewed in Appendix 2. There is a slight positive improvement in the scoring of the risks as follows:-

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to delivery highquality services.

4.2 The Trust does not deliver effective education, training and leadership opportunitiesresulting in a workforce who are unable to deliver high quality safe care.

Original Score

01.04.16

Score at Q1 Current Score

Q2

Target Score

12 12 9 6

4x3 4x3 3x3 2x3

In terms of this risk, a target score of 9 was set at the beginning of the year. This target was achieved by the end of quarter 2. As a result, the Director of Nursing has adjusted the target score to 6 in order to drive further improvement in this area. A full review of the target scores for all BAF risks will be carried out during quarter 4 alongside the refresh of the Trust’s Strategy and the risk appetite statement.

3.3 One risk has increased in score during the quarter under review.

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continueddependency on temporary staffing, affecting quality of care and financial costs.

Original Score

01.04.16


Q2

Target Score

16 16 12 4

4x4 4x4 3x4 1x4

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Original Score

01.04.16


Q2

Target Score

15 15 15 10

3x5 3x5 3x5 2x5

The main reason for the increase in score is that this risk currently has a strong correlation with BAF risk 5.1 and the associated challenges to achieve a reduction in the bank and agency spend. In addition, there is a significant risk profile of 15 and above operational risks that are aligned to this risk.

4.0 REVIEW AND THEMING OF RISKS4.1 The following themes were reported to Trust Board in April 2016 and following the end of Q1

review process, these themes are still considered to be appropriate, with the relevant updated wording: 4.1.1 Financial Pressures

The financial situation has remained challenging during Q2 and continues to be particularly affected by bank and agency as well as OATS costs.

4.1.2 Commissioning Environment Challenges continued throughout all parts of the commissioning environment during Q2, and we are currently awaiting the outcome of some significant tenders in West Lancashire and St Helens. Work continues to refresh the Trust strategy, which will sharpen our focus in relation to target patient population, and it is expected this will be presented to Board of Directors in Q4. We continue to invest in our capacity and capability not only to successfully meet the requirements of new business bids, but also to support existing services to ensure their readiness when those services are put out to tender.

4.1.3 Capacity and Flow Pressure remains in the system that is impacting on our ability to bring OATS down to our agreed planning assumption of 15. There has been a positive improvement during Q2 in OATS numbers which will be further improved with the opening of additional assessment beds at The Harbour.

4.1.4 Workforce There are concerns in relation to the current systems and processes within workforce management that impact on the Trust’s ability to ensure we have the right workforce in the right place, at the right time. The requirement to achieve the NHS Improvement agency and locum cap from 1 April 2016 continues to be challenging although improvement has been realised during Q2.

4.1.5 Patient Safety The quality and safety of patient care remains a key risk for the Trust. There has been an improvement in the risk score in relation to safe, appropriate and therapeutic environments with an improvement in the overall quality of the estate, notable reductions in admission of minors and improvements in OATS. There has been considerable work undertaken to ensure an improvement in the position in relation to health and safety risk assessments as highlighted in a recent internal audit report and the evidence to support this is awaited.

5.0 RISK APPETITE REVIEW5.1 The risk appetite statement for the organisation should be subject to an annual review. The

current statement was approved by Board of Directors in October 2015. The Trust is currently reaching the final stages of the process to refresh the strategy and provides an opportunity to reassess the risk appetite position as part of this process. The strategy refresh is due to be completed in Q4 at which point the risk appetite statement will also be reviewed and there will be opportunity as part of this process for the Board of Directors to be involved in these

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discussions. This will mean that the risk appetite statement in place currently will remain until the strategy refresh has been completed.

6.0 RECOMMENDATION 6.1 The Board of Directors is requested to approve the BAF 2016/17 Risk Register at Q2. Julie-Ann Bowden Associate Director of Compliance and Assurance

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Board Assurance

Framework 2016/17

Q2 Review

Appendix One

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BOARD ASSURANCE FRAMEWORK COLOUR CODE (KEY)

Risk Rating Matrix (Consequence x Likelihood)

Trust Board Risk Target Gap Score

Consequence

Likelihood Rare Unlikely Possible Likely Almost

Certain

1 2 3 4 5 Gap Score: 0 or <0

Risk Target Achieved

1 Insignificant 1 Low

2 Low

3 Low

4 Moderate

5 Moderate

2 Minor 2 Low

4 Moderate

6 Moderate

8 Significant

10 Significant

Gap Score: 1 – 5 Tolerable 3 Moderate 3

Low 6

Moderate 9

Significant 12

Significant 15

Extreme

4 Major 4 Moderate

8 Significant

12 Significant

16 Extreme

20 Extreme

Gap Score: 6 – 9 Close

Monitoring 5 Catastrophic 5 Moderate

10 Significant

15 Extreme

20 Extreme

25 Extreme

Gap Score: 10 Concern

Gap Score: 11> Serious

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Executive Risk Lead: CCO: Chief Operating Officer CFO: Chief Finance Officer HRD: HR Director

CEO: Chief Executive DoNQ: Director of Nursing & Quality MD: Medical Director

Strategy Priority BAF Risk Sub-

committee Exec Risk

Risk

Score

01.04.16

Risk

Score

Q1

Risk

Score

Q2

Risk Target

Risk

Target

Gap

Risk

Appetite

Guide

O1 Quality

1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services.

Quality & Safety DoNQ 16

Extreme 16

Extreme 16

Extreme 8

Significant

8 Close

Monitoring Cautious

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services. Quality & Safety DoNQ

16 Extreme

16 Extreme

12 Significant

4 Moderate

12 Serious Cautious

O2 Outcomes

2.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

Business Development and Delivery

CFO 16 Extreme

16 Extreme

16 Extreme

8 Significant

8 Close

Monitoring Cautious

2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements.

Business Development and Delivery

COO 15 Extreme

15 Extreme

15 Extreme

10 Significant

5 Tolerable

Moderate

O3 Excellence 3.1 The Trust fails to deliver holistic whole person care (physical and mental health) Quality & Safety MD

12 Significant

12 Significant

12 Significant

8 Significant

4 Tolerable

Open

O4 People

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

People HRD 15 Extreme

15 Extreme

20 Extreme

10 Significant

5 Tolerable

Open

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

People DoNQ 12 Significant

12 Significant

9 Significant

6 Moderate

3 Tolerable

Open

O5 Money 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability Finance CFO 20

Extreme 20

Extreme 20

Extreme 10

Significant 10

Concern Open

O6 Innovation

6.1 The Trust fails to plan, develop and maintain infrastructure to support the ability to deliver safe, responsive and efficient patient care

Infrastructure CFO 16

Extreme 16

Extreme 16

Extreme 4

Moderate 11

Serious Open

6.2 The Trust fails to implement the full capabilities of the new EPR which will enable the redesign of services to maximise the clinical benefits to patients and reduce the instances of incomplete patient records

Infrastructure CFO 12 Significant

12 Significant

12 Significant

9 Significant

3 Tolerable Moderate

O7 Compliance

7.1 The Trust does not comply with Monitor Licence and other regulatory requirements under NHS Improvements

Governance & Compliance

CEO 15 Extreme

15 Extreme

15 Extreme

5 Moderate

10 Concern

Averse

7.2 The Trust does not comply with statutory legislative requirements (excluding Mental Health Legislation which is covered under 7.3)

Governance & Compliance

CEO 16 Extreme

16 Extreme

16 Extreme

4 Moderate

12 Serious

Averse

7.3 The Trust does not comply with Mental Health Legislation MH Legislation DoNQ 16 Extreme

16 Extreme

16 Extreme

4 Moderate

12 Serious

Averse 60 of 71

Almost Certain

Likely

Possible

Unlikely

Rare

Minor Moderate Major CatastrophicInsignificant

Likel

ihoo

d

Consequence

5

4

3

2

1

1 2 3 4 5

7.1

6.1

7.22.1

4.1

1.2

1.1

4.2 2.2

5.1

3.1

6.2

7.3

Appendix 2 – BAF Heat Maps 2016/17

Risk Score as at 1 April 2016 Risk Score as at end of Q1

Risk Target Scores

Risk Key

HIGH

MEDIUM

LOW

Minor Moderate Major CatastrophicInsignificant

Almost Certain

Likely

Possible

Unlikely

Rare

7.3 7.1

6.1

7.2

2.1 4.1

1.2

6.2

1.14.2 2.2

5.13.1

Like

lihoo

d

Consequence

5

4

3

2

1

1 2 3 4 5

Risk Score as at end of Q2

Almost Certain

Likely

Possible

Catastrophic

Unlikely

Rare

Insignificant Minor Moderate Major

7.1

6.1

7.2

2.1

4.1

1.21.14.2

2.2

5.1

3.1

Like

lihoo

d

Consequence

5

4

3

2

1

1 2 3 4 5

6.2

7.3

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Board of Directors


Report Title Medicines Optimisation Annual Board Report and Presentation

FOIA Exemption Part Exemption Appendix One:Section 40: Personal Information

Prepared by Catherine Fewster, Chief Pharmacist

Presented by Catherine Fewster, Chief Pharmacist


Supporting Executive Director Medical Director


Report purpose To provide an annual overview of the current infrastructure, activities, developments and achievements for Medicines Optimisation across the Trust



Board Assurance Framework risk 1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services.

CQC domain Safe

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Medicines Optimisation Annual Board Report and Presentation

October 2016

Prepared by

Chief Pharmacist

Introduction

This report will provide an overview of the current infrastructure for medicines management within the Trust, the governance processes that underpin the safe and effective use of medicines and highlight areas of achievement and development.

Structure

The structure and staffing for the Pharmacy and Medicines Management team is as in appendix 1. The Prison Pharmacy service is managed within the Specialist Services Network and doesn’t sit within this structure but the Chief Pharmacist still retains Professional responsibility for any registered Pharmacy staff working within the Trust.

Definition

Medicines Optimisation vs Medicines Management

Medicines management was defined in Talking about Medicines (Healthcare Commission 2009) as the following: -

“Medicines management encompasses the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed, to optimise the contribution that medicines make to producing desired outcomes of patient care”

This has now been replaced by Medicines Optimisation which is defined as: -

“An approach to ensuring patients get the best possible health outcomes from their medicines, whilst organisations make the best use of their medicines resource”

The NICE guideline Medicines Optimisation: the safe and effective use of medicines to enable the best possible outcomes, published in March 2015 provided a platform for the Trust to develop a three year Medicines Optimisation plan. The plan aims to ensure that prescribing is cost-effective, safe and of high quality so that medicines use is optimised and unmet pharmaceutical need is met on an individual and population basis.

The Trust three year Medicines Optimisation plan focusses on the following areas: -

Systems for identifying, reporting and learning from medicines-related patient safety incidents. Medicines-related communication systems when patients move from one care setting to another. Systems supporting safe transfer of care between providers which includes the accurate medicines

reconciliation in all settings especially when patients cross care boundaries i.e. admission anddischarge

Reduce preventable deaths and minimise the burden of disease through the utilisation of medicineswhich includes both mental health and physical health drugs

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Effective implementation of NICE guidance The development of Care Pathways including the introduction and use of new drugs Monitoring antibiotic prescribing to reduce the impact of antimicrobial resistance Rationalising prescribing for wound care and continence products and appropriate formulary

management Involvement of patients and carers in decision making around medication including access to

information and choice of medication Tackling medicines waste which includes focussing on adherence and over prescribing Financial and budgetary control to ensure that we achieve financial balance

Governance

Drug and Therapeutics

The Trust Drug and Therapeutics (D&T) group meets on a bimonthly basis and is co-chaired by the Chief Pharmacist and the Deputy Medical Director.

The membership comprises a cross section of the organisation both mental health and physical health including medical and nursing colleagues.

The agenda for the meetings includes

The introduction of new drugs, Budgetary and financial control of drug expenditure for mental health and oversight of

expenditure in service lines within Networks (e.g. Rheumatology, Sexual Health, Prisons), Medication Safety including the management of medication incidents, Non-Medical Prescribing practice, Patient Group Directions (PGDs), Safe storage of medicines, Audits of prescribing practice including POMH-UK, Policy and procedural development and review Adoption of NICE guidelines and Technology appraisals, Patient Safety Alerts re medication including Never Events Guideline development for prescribing and monitoring Information resources including patient information leaflets Homecare

There are three sub groups which sit underneath the D&T

The Medication Safety Group (chaired by the Medication Safety Officer) which focusses on allaspects associated with medication safety including incident reporting and review.

The Homecare Group (chaired by the Lead Pharmacist for East Lancashire) which manages allHomecare activities re medicines in line with the recommendations of the Hackett report“Towards a Vision for the Future” published in 2011.

The Prison D&T which manages the specific issues that are pertinent to the Prison services asthey have their own procedural framework due to the complexities of handling medicines withinthe prison setting. They also have their own formulary as this comes down through thespecialist commissioners

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Controlled Drugs (CDs)

There is a statutory requirement for designated bodies to appoint a Controlled Drug Accountable Officer (CDAO) in order to meet the requirements of the Health and Social Care Act 2012 (revision 2013) and the Controlled Drug Regulations 2013. This is a delegated authority from the Chief Executive and the individual must be a fit, proper and suitably experienced person who is accountable and reports to an executive director and have no direct day to day contact with either the supply, prescribing, administration or destruction of Controlled Drugs.

The Chief Pharmacist in LCFT is the CDAO and is responsible for ensuring the safe and effective use of CDs across the organisation. On a quarterly basis the CDAO must submit a return to the Local Intelligence Network (LIN) which outlines the incidents that have occurred within the organisation. The submission is required on the 6th day of the month immediately following the previous quarter i.e. 6th July, 6th October, 6th January, and 6th April.

The reports have been submitted in a timely manner. The annual report from the Local Intelligence Network shows that LCFT has the highest reporting (399) which is considered a model of good practice in that it demonstrates that we have good systems, processes and governance in place for the monitoring of CDs. Of these 30% were illicit substance misuse in a range of settings and 50% were governance related which were mainly record keeping issues.

Drug Expenditure

New Drugs and their Introduction

The managed introduction of new drugs in particular prior to recommendations provided by NICE is key to managing the resources available and delivering good medicines optimisation. The Trust is an active partner in the Lancashire Medicines Management group (LMMG) which was established in 2013. The purpose of LMMG is to provide a platform for a consensus decision making process relating to the use of medicines across the Lancashire NHS footprint, to ensure equity in access to medicines and optimisation of medicines use. The decisions made are recommendations to the CCGs as the current statute for the establishment of CCGs does not allow for devolved accountability for decision making.

The new long acting injections (Aripiprazole and Paliperidone) for the management of Schizophrenia were reviewed by the group in January 2016 and agreement was reached re the managed introduction of these new products into the prescribing formulary. These were subsequently commissioned and funded by the CCGs in April 2016.

The introduction of the “Biosimilar” products for some of the biologic drugs used in Rheumatology has opened up the potential for significant savings. There are now plans in place to initiate new patients on the biosimilar products but agreement has still to be reached re the switching of existing patients over to the new biosimilar products. In order to realise efficiency savings there will have to be an agreement with the CCG as these drugs are recharged back to the CCG as they are PBR excluded drugs. It is anticipated that a gain share agreement can be reached in line with National guidelines which would allow for investment in existing Rheumatology services.

Horizon scanning is undertaken routinely as part of the business planning process with significant new drugs expected in the next three years for the treatment of Alzheimer’s disease, the introduction of more biosimilar drugs in respect of Biologic treatments and advances in the treatment of HIV including the use of Pre Exposure Prophylaxis (PrEP).

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The Lord Carter Review

The Carter Report “Operational productivity and performance in English NHS acute hospitals: Unwarranted variations” was published in February 2016 and appertains to Acute Hospital Organisations. As of October and November 2016 a similar exercise is being undertaken for mental health, community and specialist organisations. Whilst the expected savings from the acute model are in the region of £1billion pounds by 2020 it is not anticipated that similar savings will be released from this review. The major savings in the acute trusts are from the uptake and use of Biosimilar drugs as discussed above under new medicines and the introduction of more collaborative working across organisations in particular what are considered back office functions e.g. medicines supply, medicines procurement and stock holding. The benchmark targets also include an increase in Pharmacist prescribing, the introduction of electronic prescribing and the correct coding of medicines to ensure accurate transfer of prescribing information across interfaces. It is anticipated that more Pharmacist time spent in clinical activities will lead to greater efficiencies in prescribing and improve outcomes.

The benchmark target for clinical facing activities is 80% and provisional analysis of the activity in LCFT demonstrates that we are at 90% front facing clinical activity. As a consequence of the initial scoping the Chief Pharmacist has put forward LCFT as a potential benchmark Trust as part of the up and coming review.

Electronic Prescribing and Medicines Administration

As outlined above the introduction of electronic prescribing and medicines administration (EPMA) is seen as essential to achieving good medicines optimisation and is a key outcome measure for the Carter review.

LCFT embarked on the procurement and introduction of EPMA in 2014 with commencement and rollout in July 2015. The target for the full roll out in inpatient sites was the end of October 2016 however this has been delayed by one month with an expected completion date of the end of November 2016. This has been due to the ability to release staff to undertake the training which impacted on the roll out at the Harbour.

As part of the rollout we have been collating feedback on a regular basis with some of the comments received as below

“The prescription chart liberation society” Guild Consultant “This is very useful and makes it safer when I am on call” Community Consultant “It’s much better than I thought it would be” Staff Nurse “It actually works!” Pharmacist “I'm a complete technophobe, but it’s easy enough to use” Staff Nurse “I wouldn’t go back to paper now” Staff Nurse

Where we have had to delay roll out and staff have been asked to cover on wards where it hasn’t been introduced they have been clamouring for its introduction.

The benefits of EPMA were highlighted in a document from NHS England in 2014 and in LCFT the following are seen as key benefits which are mainly qualitative with limited cash releasing.

All prescriptions legible and complete so ensuring that patients receive the correct medication at theright time.

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System removes the requirement for rewriting prescriptions so has released time for medical staffto focus on clinical work and reduced transcription errors

Allergy section mandatory and also alerts if a prescribed drug is contra-indicated Allows nursing staff to ensure all medicines have been administered at the end of a medicines

round resulting in fewer missed dose which is a key indicator for the medication safetythermometer.

Prescription charts accessible to all staff groups at all times - even off site which allows on calldoctors to manage multiple sites

Visiting GP’s and Dentists are able to view from their bases Decision support highlights interactions making prescribing safer Allows Pharmacy to see discharge prescriptions immediately Links to Pharmacy dispensing system again preventing transcription errors Allows formulary management Fully auditable so errors are more visible. Reporting capability allows prescribing patterns to be analysed

A business case is being developed to extend the roll out into the community teams in mental health so that there will be visibility of prescribing patterns. The reporting function in the data cube will also make it considerably easier to audit practice on an ongoing basis by feeding information directly into a dashboard. This will for the first time enable comparative prescribing data analysis to look at variance in prescribing practice.

Other Key areas of Service Delivery

Non-Medical Prescribing (NMP)

NMP is undertaken by a range of practitioners to differing levels across the Trust. We have V300 prescribers who are fully independent and can prescribe within their competencies from the whole British National Formulary (BNF). V150 prescribers (Community Specialist Nurse Practitioners) and V100 (Community Nurse Practitioner Prescribers) who have a limited range of medicines they can prescribe within the Nurse Practitioner formulary. These practitioners work across arrange of settings i.e. specialist teams (e.g. rheumatology, COPD, cardiac), District Nurses, Health Visitors, Pharmacists, Mental Health Nurses.

We have nearly 500 NMPs who are registered on the Trust database as qualified prescribers and each is required to undertake an annual Continuing Professional Development (CPD) declaration which is signed off by their manager to ensure that they have the skills and competencies to prescribe. Unless this is undertaken on an annual basis the right to prescribe within the organisation is withheld.

Recent changes to the legislation have opened up opportunities for NMP to be expanded to other professional groups working in the Trust i.e. Podiatrists as independent prescribers and Dieticians to work as supplementary prescriber’s for complex regimes that have been initiated in secondary care

In 2015 we were asked to take over the governance and management of the NMPs working in GP practices in Greater Preston and Chorley and South Ribble CCGs. This resulted in funding for an extra post to support this role and also to further enhance the education and training support for CPD.

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In order to streamline CPD we have recently introduced an electronic declaration which can be mapped to the BNF codes so we can analyse the types of prescribing taking place.

Each year we participate in the regional NMP audit and we always submit a large number of audit information which provides assurances around practice. We undertake an annual audit of antibiotic prescribing that is undertaken by NMPs in order to ensure that we are not contributing to the over prescribing of antibiotics. We have two Commissioner driven performance standards for prescribing by District Nurses i.e. wound care and continence products. The requirement for both is that prescribing is within 80% of formulary and current figures are showing over 90% compliance for wound care.

Education and Training

A key area of development in the last twelve months has been the appointment of a medicine education and training lead and the development of e-learning packages to support essential training across a wide range of drugs groups.

Administration of Medication Controlled Drugs (LCFT Premises & Offender health) Controlled Drugs (Non-LCFT premises) HCSW/HCA - Witnessing Controlled Drugs Prescribing Standards Medicines Management Level 1 Medicines Management Level 2 Refresher Module Medicines Management Level 3 Refresher Module Patient Group Directions Antimicrobial Stewardship Mental Health Medications Clozapine Rapid Tranquillisation Lithium Introduction to Diabetes Mellitus Management of Venous Thromboembolism

There is continuing development of further packages where requested

The introduction in August 2016 of an assessment of FY1 prescribing competencies has allowed us for the first time to be able to put systems and processes in place to ensure that we have a competent medical workforce in terms of prescribing. Although not the results that we would have hoped for this has ensured that junior doctors have the appropriate supervision and sign off around their competencies and skills as a prescriber which ensures patient safety.

Medication Safety Officer (MSO)

The appointment of a medication safety officer (MSO) was mandatory from 2015. This role in LCFT is undertaken by one of the medicines management nurses. This represents only a handful of nurses that have been appointed to this role but the requirement was not prescriptive to a specific profession.

The MSO chairs the medication safety group and also is responsible for circulating CAS alerts received in respect of medicines, providing performance reports for the Commissioners re medication errors, focussed pieces of work in specific drug areas e.g. clozapine and liaising on a national basis with NHS England re the MSO network.

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The Trust has a good reporting of medication incidents through to the National Learning and Reporting System (NRLS). This is in part due to the activities of the Pharmacy team who record their interventions into prescribing where the majority of these are classed as near misses.

Medicines Management Nurses

In order to encourage a more reflective approach to the management of medication incidents and errors the role of the medicines management nurse was introduced into LCFT in 2010 and now includes three members of staff. In 2015 the procedure for the management of medication errors was also rolled out to all professional groups who make a medication error including prescribers. The learning culture created by this reflective approach has ensured that there is open reporting of incidents and we are beginning to see an increase in the numbers of self-reports from medical staff where they have made errors.

The main challenge is in capturing near misses as if we could start to capture these we can then prevent an incident from actually occurring. Work is on-going to publicise examples of the types of near misses that should be placed on Datix.

We are also keen to promote and encourage yellow card reporting which is the national reporting system for adverse reactions to medicines. This can be undertaken by professionals and patients and has recently been broadened out so that patients can also report where there has been an error in practice i.e. administration of the wrong drug or a prescribing error.

Learning Disabilities

We have appointed a dedicated Learning Disability Pharmacist to work alongside the team in reviewing prescribing in particular for those patients that are being repatriated from other care facilities as part of the Winterbourne review. The prescribing patterns seen are complex but the overall aim is to ensure the appropriate prescribing of psychotropic medication in this patient group so that it meets best practice guidelines, minimises the risk for the individual patients and reduces the overall lifetime risk of developing severe and enduring side effects.

Challenges and Developments

Community Mental Health Prescribing

Approximately 80% of the mental health drug budget is spent in community teams, and yet these teams are poorly resourced with medicines management staff.

With the current establishment Pharmacists spend time undertaking tasks that could be done by a clinical pharmacy technicians e.g. storage audits, update of medication snapshot, response to clozapine plasma levels. Releasing this time would facilitate greater clinical input and medicines optimisation in the community teams by pharmacists, better oversight of prescribing practice. This could potentially generate additional savings on drug expenditure and lead to improved outcomes for patients. Audit and clinical experience has also demonstrated areas of poor physical health monitoring and recording of medication regimens in community teams.

A pilot project has been undertaken in Ormskirk CMHT to examine the benefits of putting a Clinical Pharmacy Technician into the team to address the issues highlighted and promote high quality care. This has generated the following as key outcome indicators for the development of this role

They would assess pharmaceutical care needs of community patients

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They would highlight against standard criteria those who would benefit from a pharmaceuticalreview by a pharmacist. Such criteria would capture high dose prescribing, polypharmacy andhigh risk medicines targeting the limited pharmacist resource to those who would most benefit.

They would ensure that the routine monitoring required by specific medications was undertakene.g. Lithium levels and associated blood tests, clozapine plasma levels,

They would ensure that the annual physical health monitoring as required by NICE, CQUINsand the vision of the Five Year Forward View including blood tests, blood pressure, weight,indicators for metabolic syndrome, smoking status and routine screening were up to date byaccessing Path lab records, GP records etc.

They would highlight those patients that could be transferred back to GP prescribing undershared care

The potential gains by undertaking this would be improved outcomes for patients through rationalising prescribing practice, better physical health monitoring, potential savings on the prescribing budget and savings on prescriber and clinic time through an overall reduction in repeat prescribing and monitoring.

Antimicrobial Resistance

In line with national recommendations we are required to demonstrate good governance around the prescribing of antibiotics. Across the Trust our current prescribing of antimicrobials is very low and in mental health this is largely in the inpatient setting. All antibiotic prescriptions are reviewed in line with the following criteria and this is reported on a quarterly basis to the Infection Control group.

Prescribing within agreed formulary for the locality (this varies across Lancashire due tosensitivities in each area)

Ensuring appropriate use i.e. for recognised conditions Ensuring appropriate sensitivities Ensuring appropriate courses of treatment with specific stop dates

In the community there is an annual audit of antibiotic prescribing undertaken by NMPs and this is reported on to the CCGs as part of the commissioning framework.

The development of community IV antimicrobial services requires more in depth monitoring and in line with the national patient safety alert and the NICE guideline on Antimicrobial Stewardship there is recommendation that an antimicrobial stewardship team be established which includes an antimicrobial Pharmacist.

Medicines Administration

The current procedural framework for the administration of medicines focusses on the role of the qualified nurse. A review is currently underway to examine whether as part of expanding roles that administration could be a delegated practice to non-registered staff. It is envisaged that this will provide clarity around the scheme of delegation and the underpinning competency and educational framework that would be required to support this.

Outcomes

How we measure outcomes from good medicines optimisation is challenging and this will form the key piece of work for the Trust moving forward. The NHS spends approximately 5% of its annual budget on drugs and this is growing year on year with increased prescribing across a wide range of conditions.

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The new developments on the Horizon for a range of conditions e.g. the use of the newer biologic drugs in Alzheimer’s disease, whilst representing key developments, will be costly.

The aim will be to try and establish key outcomes whether it be prevention of admissions or more importantly what is important for the individual patient e.g. health and wellbeing, employment, relationships etc. By utilising outcome measures we can try to focus on what our expenditure and prescribing of medication delivers rather than just measuring activity.

Physical Health

As outlined above physical health for our patients with a diagnosis of mental illness is key. The Five Year Forward View focusses on ensuring that the physical health of patients should be equally as important as their mental health and it should not be viewed separately. With mortality rates for patients with a mental health diagnosis higher than the general population it is essential that we start to address these issues.

The medications that we prescribe are also part of the problem in that they aggravate obesity, cause diabetes, contribute to cardiac disease through increasing cholesterol and lipid levels and lead to increased mortality levels. We therefore need to ensure that patients get targeted treatments that take account of pre-existing morbidity and that medication is reduced to the minimum that will allow the patient to remain well with significant reductions in polypharmacy. We also need to ensure that appropriate physical health monitoring takes place and that patients receive advice and support to manage emerging physical health problems e.g. weight management, smoking cessation, exercise and access to appropriate prevention advice.

Key Achievements and Successes

The development of prescribing in Post-Traumatic Stress Disorder (PTSD) for the management ofnightmares which was presented at National Conference and is currently awaiting publication.

The development and publication of an innovative way to manage temperature variations in thestorage of medicines. This was developed in partnership with Quality Control North West andrepresents the first method of managing this issue without having to destroy large quantities ofstock medication.

The successful negotiation with Commissioners for funding of the new Long Acting depot injections. The development of a comprehensive education, training and assessment package for all

professional groups involved in medicines optimisation. The development of an electronic CPD revalidation process which is the first in the country which

we will showcase at the next NMP conference. The development of more appropriate tools for monitoring of side effects in older adults with mental

health problems The roll out of electronic prescribing which was viewed by CQC at the recent review as an example

of good practice nationally.

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