Meeting Book - Council of Governors meeting Thursday 23rd ... M/Council of Governors papers April...

17.35 Minutes of previous meeting and matters arising Trust Chair

17.40 Action log Trust Chair

4. Chairs Report .pdf - 6

17.45 Chair's Report Trust Chair

17.55 Chief Executive report ChiefExecutive

6. Nominations Committee Update.pdf - Page 34

18.10 Nominations Committee / Trust Chair's Appraisal TrustSecretary/LeadGovernor

7. B&P Summary Report.pdf - Page 40

7.1 Integrated Performance Report.pdf - Page 44

7.2 Finance Summary report.pdf - Page 49

7.21 Finance summary M11.pdf - Page 51

18.15 Business and Performance Report Summary Geoff Turral,CommitteeChair

18.20 Quality, Safety and governance Summary update BrianBenneyworthCommitteeChair Mike

18.25 Audit and Assurance Summary report MikeHindmarch,CommitteeChair

2.FINAL COG Minutes Dec 2019.pdf - Page 2

3. Action Log Dec 2019.pdf - Page 13

4.1 NED activity logs.pdf - Page 21

5.CEO Report.pdf - Page 29

18.05 Governor Questions Trust Chair

6.1Trust Chair's Appraisal Report.pdf - Page 38

7.3 FOI IGSG Committee Report.pdf - Page 56

8. QSG Summary Report.pdf - Page 62

AAC Summary Report.docx - Page 65

Meeting Book - Council of Governors meeting Thursday 23rd April 2020

Agenda

Page 1 of 68

Minutes of the Council of Governors Meeting

held on Monday 2nd December 2019 at Weston Homes Stadium,

Peterborough, PE2 8AL from 17.30 – 20.00

Members Present

Julie Spence Trust Chair

Margaret Johnson Public Governor, Cambridgeshire

Kripa Dwarakanath. (Interim) Public Governor, Cambridgeshire

Keith Grimwade Lead Governor, Carer Governor,

Cambridgeshire

Helen Brown Public Governor, Rest of England John Parks Public Governor, Peterborough David Westbrook Public Governor, Peterborough Ollie Ayres Staff Governor Matthew Barker Staff Governor Adrian Howson Public Governor, Cambridgeshire Hannah Touhey Service User Governor, Cambridgeshire Fiona Kerr Public Governor, Cambridgeshire Nora O’Shea Staff Governor Graham Wilson Appointed Governor, Cambridgeshire City

Council Rick Harris Public Governor, Peterborough In Attendance:

Tracy Dowling Chief Executive Officer

Scott Haldane Executive Director of Finance

Stephen Legood Director of People and Business

Development

Rachel Gomm (Interim) Director of Nursing

John Martin (Interim) Director of Operations

Julian Baust Non-Executive Director

Sarah Hamilton Non-Executive Director

Geoff Turral Non-Executive Director

Brian Benneyworth Non-Executive Director

Mike Hindmarch Non-Executive Director

Anna Tuke Associate Director for Involvement and

Partnerships

Hannah Wysoki Charity Manager

Cathy Walsh Deputy Medical Director

Claire Milbourne Corporate Governance and Engagement

Manager

Agenda Item 2

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Apologies: Sarah Warner Director of Service Transformation Chess Denman Executive Medical Director Peter Jones Non-Executive Director Jo Lucas Non-Executive Director Angela Single Advisory Non-Executive Director

Margaret Peers Public Governor, Cambridgeshire Norest Mararike Staff Governor Charlotte Black Appointed Governor Susie Willis Appointed Governor, Care Network Stephen Mallen Public Governor, Cambridgeshire Maggie Barker Public Governor, Peterborough Mark Prince Service User Governor, Peterborough

Kit Connick Director of Corporate Affairs

Caroline Macpherson Interim Associate Director of Corporate

Governance and Trust Secretary

ITEM DESCRIPTION ACTION BY

1.

Welcome, Introduction, Apologies for Absence and Declarations of Interest The Trust Chair welcomed those present to the meeting. No conflicts of interests were declared.

2. Minutes The minutes of the Meeting held on 9th September 2019 were agreed as an accurate record and presented to the Chair for signature.

3. Action Log/ Matters Arising Matters arising In response to concerns previously raised by Governors with staff PRIDE awards possibly not being fully representative of the Trust as a whole, the Trust Chair gave a verbal update on behalf of the Director of Corporate Affairs on the following: The Trust has identified that Fenland and Hunts seem to be under- represented. The Directorates are proportionally represented, as are the localities, with the exception of Ely and the Fens. Rough calculations indicate that the Directorate/locality proportions are correct other than Fenland and Huntington, but we want to validate this with more accurate staffing numbers for each of the localities.

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There had been a push for nominations earlier this year across Fenland. However, these had declined again in October. This could indicate that the Awards are not embedded in the Fenland locality team culture, so work will be done with the Directorates to support them to encourage staff to have awareness of the PRIDE awards and nominate staff. ACTION: Further update on the above to be provided at the April Council of Governors meeting. In response to a concern that the “field force” might be under-represented, the Council was asked to note the following: The number of nominations has consistently increased over the last two years. October 2019 had seen an increase of 65 nominations compared to the previous year. Frontline patient-facing staff are well represented, accounting for around half of all nominations in October 2019. There is more that can be done to ensure that all teams understand the awards process and nominate staff. However, it was noted that continued growth of nominations at the current rate may pose some logistical and resource challenges, so the approach itself may need a review. In response to a question asked around the balance of awards between the five PRIDE categories, the Council noted the following: Professionalism is the most common value nominated, followed by Empowerment. Professionalism is a more general value compared to others and is the usual default if it’s debatable which ‘category’ most closely matched the nomination. Innovation tends to be the lowest area across each nomination period, although there are lots of good examples of innovation across the Trust. However, in line with CQC feedback there seems to be a Trust culture of ‘modesty’, where staff don’t always acknowledge that they are being innovative. This is being addressed as part of a wider Trust culture piece. However more can be done via the Quality Improvement work that the Trust is also focusing on. Action 16 The Chief Executive updated the Council on the Tier 3 Children’s waiting lists noting the following points:

• The Children’s waiting list continues to give the Board more concern than other areas that fall within the Trust.

• We know that children are waiting too long. However, there are currently no national waiting time standards for Child and Adolescent Mental Health Services (CAMHS).

• NHS Improvement have advised on several recommendations to simplify waiting lists.

• A piece of work is currently taking place to introduce the SystmOne IT system into mental health service to replace RIO (the ‘OneVision’ programme), with the initial redesign work prioritising the Children, Young People and Families Directorate.

• The Commissioners have agreed an additional £200,000 in this year’s financial settlement for access appointments.

Director of Corporate Affairs

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• Recruiting into CAMHS services is a challenge both nationally and locally.

In response to a question asked around delays and the need for preventative care to stop conditions worsening, the Chief Executive noted the importance of early intervention and highlighted the need for a System-wide piece of work to look at the totality of available support services and the need to match capacity with demand. ACTION It was noted that an update would be presented at the April Council of Governors meeting and the Chief Executive welcomed the Council’s input in future projects.

Action 17 The Director of People and Business Development noted that the Council of Governors had been briefed on the New Care Models at an earlier Development Session and agreed to circulate further information on CAMHS funding to the Council. All other actions were noted as complete or not yet due.

Chief Executive

Representing the interests of, and communicating with the Trust’s membership

4. Chair’s report The Trust Chair presented her report to the Council of Governors, highlighting the following: Well-Led Review The informal feedback from the Well-Led Review was presented to the Board on 28th November. The Chair thanked the Governors who were interviewed as part of the Review and noted that the public feedback will be shared and any actions taken from the Review will form an internal plan. ‘Thank you week’, The Trust Chair noted that the ‘Thank you week’ led by the Corporate Governance and Engagement Manager had been recognised by NHS Providers and presented with a Membership Showcase award for the engagement activities that took place as part of the ‘Thank You week’. STP It was noted that as we are in the pre-Election period, normal business would resume after the 12th December and the STP draft response to the NHS Long Term Plan (LTP) would be presented in the public arena for approval after the 12th December. Joint Councils of Governors’ meeting The Trust Chair thanked the Lead Governor for his efforts in organising the first joint Councils of Governors’ meeting between CUH, Papworth, NWAFT

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and CPFT and thanked the late Elizabeth Mitchell without whom it would not have happened. The ‘Surviving Winter’ campaign It was noted that that approx. 33,000 homes will be in fuel poverty this winter, resulting in greater risks of exacerbated physical and mental health conditions. The Trust Chair encouraged Members of the Council and those in attendance to direct anyone suffering from fuel poverty to Citizen’s Advice in Cambridge, where grants of up to £300 were available. The Council of Governors noted the contents of the report

5. Chief Executive’s Report The Chief Executive presented her report, highlighting the following: Developing the organisational culture

• Focusing actions around driving out bullying and harassment.

• Developing the Heart and Soul pastoral care strategy.

• Quality Improvement initiatives and plans to introduce a ‘Just Culture’ framework for learning, looking at how we treat each other when things don’t go as expected in a kind way that is consistent with real learning.

• Updating all Human Resource policies and procedures to put fairness and just and civil practice at the centre of our practices.

Development of exemplar models for community mental health services

• CPFT have been successful in securing just short of £6mfor mental health services in the community. The funding will be invested over the next two years to seek to achieve the clinical standards that are defined in the NHS LTP.

• An additional £1m has also been received for community adult Eating Disorder Services to enable implementation of pathways for self-referral, early intervention and improved medical monitoring.

In response to a question around the EU exit risks, preparedness and planning, the Chief Executive assured the Council that plans are in place for the end of January which are robust and rigorous given that it is in the depths of winter. The Governors noted the contents of the report.

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6. Governor Update The Lead Governor presented the Governor update report, highlighting the following:

• The report is a good indication of the involvement of Governors and

the work that Governors are carrying out outside of the organisation.

• It is clear from the report that Governors are attending or hosting

meetings wherever possible, to hear feedback from Members.

• Governors are encouraging the general public and service users to

get involved with the CCG’s BIG consultation.

Strategy

7. Head to Toe update The Charity Manager delivered the Head to Toe presentation and noted the following highlights:

• The last quarter has shown a change in the way people think of the

Charity strategically.

• The Charity is focusing on its long-term strategy, working on aligning

it with the NHS LTP.

The Council of Governors were invited to offer comment or involvement in how the Charity embeds its mission, strategy and priorities into the culture of CPFT. ACTION It was noted that the charity Manager would come to a future Development Session to talk about the Charity further. In response to a question asked about embedding the Charity and how it plans to raise awareness amongst patients, the charity Manager noted that plans are already underway to repurpose the ‘living well, living with’ forum to be an environment where staff and service users can bring charitable funding projects for consideration. Members thanked the Charity Manager for her update and the presentation.

Corporate Governance and Engagement Manager

7. Children’s Hospital Update The Deputy Medical Director presented an update on the Cambridge Children’s Hospital programme, with the following highlights: Overview –

• Cambridge Children’s Hospital is a collaboration between CPFT and

Cambridge University Hospitals FT and the University of Cambridge.

• The hospital will offer an innovative model of integrated physical and

mental health care, underpinned by World-class research.

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• The hospital will be built on the Cambridge Biomedical Campus.

5 key benefits that Cambridge Children’s is hoping to achieve are:

1. Improved Clinical outcomes through integrated care.

2. Value for money - population health and system benefits.

3. Academic excellence leading to pioneering treatments and future

prevention.

4. Informatics for care and research.

5. Building future resilience.

Headline Progress since the last report Business Case development –

• Submission of revised strategic outline case in November 2019.

• Agreement for drawdown from £100 million subject to the Strategic

Outline Case (SOC) approval, currently estimated to be in March.

• CPFT are exploring with NHS England and Improvement whether

the project will be required to follow the Material Transactions

Guidance.

Communications –

• A working name and brand has been identified - ‘Cambridge

Children’s’.

• The “Yellow Book” and website has been launched.

• The project features in local and regional media.

• Secretary of State for Health and Social Care, Matt Hancock, has

visited the site.

Engagement -

• A stakeholder and engagement mapping strategy has been

completed.

• Visits to regional hospitals have taken place.

• Multi-Agency workshops have taken place.

Fundraising –

• An interim Director of Fundraising has been appointed.

• There are now two Co-Chairs for the Fundraising Campaign Board.

• A fundraising feasibility study and the development of a campaign

strategy is now in development

Integrated models of care –

• A series of workshops with Cambridge University Hospitals and

CPFT clinicians have taken place.

• Visits to other centres and children’s hospitals have taken place.

Design and Construction –

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• Linking in with the development of the proposed ‘Addenbrookes 3’

programme and the Cambridge Biomedical Campus master

planning.

• Due to the delay in the timeline from 2023 to 2025, interim solutions

are being considered for the re-provision of Tier 4 wards from the

Ida Darwin site prior to the move to Cambridge Children’s.

In response to concerns expressed about what long term financial support will be in place to support services as well as the physical build, the Director of Finance advised that opportunities are currently being explored around whether or not there may be people who are willing to fund services as well as the build. In response to questions around the timeline for Local Authority and public engagement, the Deputy Medical Director confirmed that plans are in development for a consultation regarding the Tier 4 move. The Council of Governors noted the contents of the report and thanked the Deputy Medical Director for the presentation.

Governor Question on Performance of the Trust

Annual Operational Plan The Director of Business and People gave a verbal update highlighting the following:

• The development of the Annual Operational Plan will commence in January 2020.

• Governors are invited to take part in the development.

Zero Suicide Ambition The Associate Director of Involvement and Partnerships presented the Zero Suicide Ambition report, highlighting the following:

• Risk Assessments – an agreement has been made across all Directorates to use the same framework that is being rolled out with GP’s and MIND. This mean that there is a common language and a shared understanding of risk across the System.

• Cambridgeshire has been identified as a pilot site for real-time monitoring of suicide numbers.

In response to a question asked about national statistics increasing for suicide rates, the Associate Director of Involvement and Partnerships noted that as an area Cambridgeshire is following the pattern of trends nationally. The Governors noted the contents of the report.

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Membership working group report The Lead Governor noted that Membership Working Group’s main focus in the new year would be focusing on increasing the public membership.

8. Business and Performance Summary As Chair, Non-Executive Director, Geoff Turral, presented the Business and Performance Committee (B&P) report, highlighting the following:

• Children’s Hospital – Interim arrangements are being looked at for the relocation of the services on the Ida Darwin site, due in 2023.

• Agency report – Year to date Agency costs are 9% less than the year to date ceiling target.

• Integrated performance report (IPR) – A lot of work is taking place to improve the report and change it in presentation form in terms of the red / amber / green system that is currently in place.

ACTION: Governor Development Session to be arranged for training in the new IPR reporting system. In response to a concern raised by the Governors around the Integrated Performance Report (IPR) not reflecting the work of the Trust as a whole, the Director of Finance confirmed that the current IPR largely reflects prescribed metrics. However, the Statistical Process Control (SPC) process will allow the report to be more flexible and allow for focus on issues that have more relevance. ACTION: It was advised that Governors will have an opportunity to comment on the proposed set of indicators before the revised report is finalised. The Executive will consider the report content to ensure the breadth of services provided by the Trust are reflected in the report, as well as the nationally and locally prescribed metrics.

ACTION: It was also noted that the Freedom of information quarterly report should be presented at all future meetings

In response to a question about the Digital Strategy and why the Office 365 initiative had been paused, the Director of Finance noted that a piece work needs to take place to ‘re-image’ CPFT devices and desktops before the project can move on. This piece of technical work is inextricably linked with the move to a new ICT services contract with NHS Shared Business Services (SBS). This work is scheduled to be completed early in the new year as part of the transition to the new service model with SBS. Governors also raised concern around the cost Improvement Plan (CIP) targets not being met. The Chair of B&P and the Director of Finance noted these concerns and confirmed every effort was being made to realise a greater level of recurrent efficiencies across the Trust. The Council of Governors noted the contents of the report.

Corporate Governance and Engagement manager/ Director of Finance Director of Finance Trust Secretary /ADO Corporate Governance

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9. Quality Safety & Governance Committee Summary Non-Executive Director Brian Benneyworth presented the Quality, Safety and Governance Committee (Q,S&G) report, highlighting the following:

• 9 month positive trend on pressure ulcers.

• Positive reduction in falls in the Older People and Adult Community (OPAC) services.

• Positive reduction in Agency levels.

• Staff sickness continues to fall below target.

• Freedom to Speak Up – CPFT were ranked as second in the national Freedom to Speak Up index.

• Food scores are still low – The Committee continues to monitor and look for ways of improvement.

• An increase in self-harm and physical assault has been recorded in the Children, Young People and Families Directorate – the Committee has sought further assurance/information and actions.

Lack of progress in identifying relevant quality outcome measures. The Chief Executive asked the Council to note that the outcome measures are identified, and the issue is a national issue around having the reporting mechanisms in place to accurately record them.

• The Committee is expecting a future report on the recent changes to the Mental Health Act.

In response to a question around the exit interviews and CPFT not meeting annual turnover and recruitment rate targets, the Director of People and Business Development noted that the following issues prevent meeting the recruitment targets: references and the timeframe in which adverts are posted by managers. ACTION: Public Governor, Adrian Howson raised a query about the apparent contradiction between the reduction in falls and pressure ulcers within the OPAC Directorate and the low safety scores recorded for the year. It was agreed that the Interim Director of Nursing, Quality and AHPs would follow up and report back to the Council. The Governors noted the contents of the report.

Interim Director of Nursing

10. Audit and Assurance Committee Report Non-Executive Director Mike Hindmarch presented the Audit and Assurance Committee report, highlighting the following:

• The Committee had expressed concerns about the completion of the annual Internal Audit plan and associated reporting. It was these elements that would form the basis of the annual Head of Internal Audit (HoIA) Opinion that, in turn, formed part of the External Auditors view of the Annual Report and Accounts. The Committee were aware that the lack of progress was partly down to lack of resource with the internal auditors as well as response times from Executive Team sponsors, largely due to competing workload

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pressures. However, assurances had been given by both BDO, the Trust’s Internal Auditors, and by the Director if Finance on behalf of the wider Executive Team that all outstanding/expected Reports would be completed to ensure the HoIA Opinion would be provided as required.

Given that the current contract for External Audit was due to expire in December this year, a procurement exercise for the appointment of new External Auditors had been carried out. However, despite advertising through two independent Frameworks, there have been no applicants. Recognising the appointment of the Trust’s External Auditors was a prescribed responsibility of the Council of Governors, the Director of Finance updated the Council on a proposed option: The Director of Finance noted that CPFT’s contract with the current External Auditors, Grant Thornton will come to the end of its two-year extension on 31 December 2019, the original contract having been for a core period of 3 years, plus two one year options. Therefore, the Council of Governors were asked to APPROVE the decision to extend the contract for External Auditor by a further year with Grant Thornton on the basis that the Trust would not be open to challenge under Competition Regulations, given there had been no response to the aforementioned Framework adverts. On the basis of this proposal, The Council were also assured that the Committee will continue to look for possible applicants well before December 2020. Given the circumstances, the Council approved the proposed extension with Grant Thornton.

Date of next meeting : 23rd April 2020

Signed…………………………………………………. Dated……………………………

Julie Spence, Trust Chair

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Agenda Item: 3

Council of Governors

ACTION LOG updated from the meeting held on 2 December 2019

Action log

number Date of Meeting

Agenda Item

Action Due Date Lead Status

1. 9 September 2019

Quality, Safety and Governance

The Council of Governors to be given a list of other services in the East of England that provide CAMHS services.

January 2020

Director of People and Business Development.

UPDATE: Agreed that the director of people and business will circulate further information to the Council of Governors.

2. 2 December 2019

Matter Arising – Pride Awards

Further information around PRIDE awards to be presented at the next Council of Governors meeting.

April 2020 Director of Corporate Affairs

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3. 2 December 2019

Head to Toe Charity Update

It was noted that the Head of Charity will come to a future Governor Development session.

April 2020 Corporate governance and Engagement Manager

Complete: Charity session has been arranged for the Governor induction on July 15 and will become an annual session.

4. 2 December 2019

Business and Performance Summary

Governor Development session to be arranged to cover the New integrated Performance Report.

April 2020 Corporate governance and Engagement Manager/ Director of Finance

5. 2 December 2019

Business and performance Summary

It was noted that the Governors would have the opportunity to comment on the revised set of indicators for the IPR report before they are finalized.

February 2020

Director of Finance

6. 2 December 2019

Business and performance Summary

A request was made for quarterly freedom of information updates to be presented at future Council of Governor meetings

April 2020 Interim Associate director of Corporate Governance/Trust Secretary

COMPLETE: Report included in Agenda Item:

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7. 2 December 2019

Quality, Safety and Governance summary

In response to a query around the contradiction between the reduction in falls and ulcers within the OPAC Directorate and the low safety scores it was agreed that further clarification would be provided.

January 2020

Interim Director of Nursing

ONGOING: a meeting between the Lead Governor and Interim Director of nursing has taken place.

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COUNCIL OF GOVERNORS MEETING IN PUBLIC

Agenda Item:4

Subject: Chair’s Report

Date of Meeting:

Thursday 23rd April 2020

Author:

Caroline Macpherson, Interim Trust Secretary

Responsible Lead:


Lead Director:


Report Purpose: (please mark in bold)

To Note Information Decision Approval Ratify

Link to CQC KLoE: (please mark in bold)

Safe Effective Caring Responsive Well-Led

Link to Trust Strategic Goals: (please mark in bold

where applicable)

DELIVER THE BEST

CARE

INNOVATION IN

HEALTHCARE & RESEARCH

DEMONSTRATE BEST VALUE

IMPROVED WORKING

EXPERIENCE

Financial Impact Legal Impact Impact to Partnership working: (please mark in

bold where applicable, and explain)

FINANCIAL LEGAL ENGAGEMENT PARTNERSHIP

WORKING

As detailed in the report.

Confidentiality / FoI status: Public Report

Committees / groups where this has been presented before:

N/A

Committees / groups where this should next be considered:

N/A

CHAIR’S REPORT

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1.

INTRODUCTION / BACKGROUND

The purpose of this report is to provide an update to the Council of Governors on any matters that have arisen and/or developed since the last Council of Governors meeting held on Monday 2nd December 2019.

2.

COVID-19 – GOVERNANCE ARRANGEMENTS

In light of pressures on the NHS caused by the Covid-19 major emergency and the need to maintain effective governance, while supporting the Executive and the Trust, the following changes have been implemented and became effective from the board meeting held on 1st April 2020:- Major Incident Response The Trust has undertaken a number of desk top planning exercises with operational and corporate teams to prepare for Covid-19. We have now moved to major incident response, operating a fully functioning Incident Control Centre (ICC) from Elizabeth House, which includes Gold, Silver and Bronze command. Business Continuity All non-essential services have been stood down, with further services under review, although we are continuing to maintain service delivery for critical business functions at this time. A number of staff are now having to self-isolate and given current guidelines and school closures the number is likely to increase over coming days and weeks. Governance Arrangements With immediate effect, all meetings will move to virtual or live streaming ‘Teams’ meetings. Specific meeting joining details will be cascaded appropriately in line with meeting cycle of business deadlines, however broader arrangements are outlined as follows: Board of Directors Meeting (Public and Private)

• Lead Contact: Caroline Macpherson, Interim Trust Secretary.

• Meeting duration for Public Board will be 2 hours, starting at 09:30hrs.

• Meeting duration for Private Board will be 1 hour, starting at 12:00hrs.

• Update reports should be no longer that 4 pages long, outlining: i) key issues; ii) assurances; and iii) the Covid-19 affected position.

Board Development Day


• The next Board Development Day is scheduled 28th April 2020.

• This day now be reduced to a 1-hour virtual Teams meeting, starting at 09:30hrs.

• Focus of the day will be specifically around the Trust Covid-19 response.

Quality, Safety and Governance (QSG) & Business and Performance (B&P) Committees


• QSG and B&P meetings will go ahead on the 29th April 2020.

• Both meetings will be combined into a 90-minute virtual Teams meeting, starting at 09:30hrs.

• Update reports should be no longer than 4 pages (maximum), outlining: i) key issues; ii) what the Committee is assured on; iii) what the Committee isn’t assured on; iii) current Covid-19 affected position.

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Audit & Assurance Committee (AAC)


• AAC meeting will go ahead on the 15th April 2020 as a virtual meeting, starting at 10:00hrs, for 90 minutes.

• Update reports should be no longer than 4 pages (maximum), outlining: i) key issues; ii) what the Committee is assured on; iii) what the Committee isn’t assured on; iii) current Covid-19 affected position.

Charitable Funds Committee (CFC)


• CFC meetings will be stood down until further notice.

• Charitable fundraising activities have been temporarily suspended.

• Finance will continue to monitor expenditure and budgets. Remuneration Committee (RC)


• The next RC meeting will be held virtually on 11th June 2020. Nominations Committee (NC)

• Lead Contact: Caroline Macpherson, Interim Trust Secretary. Council of Governors (CoG)

• Lead Contact: Claire Milbourne, Corporate Governance & Engagement Manager.

• The next CoG meeting will go ahead on the 23rd April 2020.

• The meeting will be held as a live streaming teams meeting.

• In order to provide reassurance and keep Governors aligned with Trust business and pressures on staff and wider system, written updates will be prepared and circulated prior to the meeting.

• Any questions to be raised should be sent in advance of the meeting.

Governor Development

• Lead Contact: Claire Milbourne, Corporate Governance & Engagement Manager.

• Pre-scheduled Governor development sessions will be stood down until further notice.

• Governors will be provided with regular updates on Trust issues during this time and can be assured that all National Guidance, as it relates to Trust services, is being followed.

Joint Venture Partnership Board (JVPB)


• Pre-scheduled JVPB meetings will be stood down until further notice. 2019/20 Annual Report


• Preparations are continuing to deliver the annual report to the current timescales.

• The Trust will ensure we are compliant with current guidance, but will take a light touch approach, only including the mandatory sections.

Well Led Review


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• Preparations are continuing to deliver the well led review action plan, and staff are being asked to provide updates.

Service Visits


• All pre-planned service visits will be stood down, unless there are specific requirements for a staff welfare visit in relation to Covid-19 (as directed by the Gold Command tier). A central list is being maintained for all Executive and Non-Executive Directors who are self-isolating.

Buddy Arrangements


• A buddy/deputy system has been introduced to help support and maintain leadership, should primary staff become unavailable.

• Non-Executive Director buddy arrangements are identified as follows: ➢ Julie Spence/Julian Baust ➢ Brian Benneyworth/Jo Lucas ➢ Geoff Turral/ Mike Hindmarch

• Executive Director Gold Command arrangements are identified as follows: ➢ No 1) Tracy Dowling ➢ No 2) Scott Haldane ➢ No 3) Kit Connick

Gerard Newnham will shadow at present. All Directors have identified two deputies/alternates should they become unwell or absent from work.

Communications

• To maintain effective communication, Tracy will send a weekly communication update to Board members outlining the current Trust position, this is in addition to the daily staff news that is being shared.

CQC

• CQC inspections have been suspended, however Mental Health Act (MHA) visits to inpatient areas will continue.

• The Trust will continue to maintain a light touch oversight of CQC actions and potential areas that could be affected by Covid-19 (e.g. seclusion and quality/safety).

Arrangements outlined will be kept under review to ensure effective governance is maintained. All feedback is welcomed as the system embeds.

3. NON-EXECUTIVE DIRECTOR APPRIASALS

The appraisals for all the Non-Executive Directors have been completed - we currently have a very engaged group of Non-Executive Directors who support, guide and challenge the directors and work well together for the benefit of the patients, service users and the wider system. Governors should note:- The following NEDs i.e. Jo Lucas, Mike Hindmarch, Geoff Turral and Brian Benneyworth are continuing with their current 3 year terms.

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Angela Single has completed a year as a part time non-executive director and is actively applying for full time roles. She left the trust in February and we wished her luck in her search for a NED role. This role is not being replaced. Sarah Hamilton has a portfolio career and the tribunals she chaired frequently fell on the days of the board, board Development or Sub Committee meeting dates consequently she decided to resign from 31st March 2020 as she was unable to fulfil the requirements of the role. The Governing body are consequently recruiting a replacement, this process is being led by the Chair in consultation with the Lead Governor. Nominations Committee shortlisting took place on 15th April and we have a diverse pool of potential candidates identified with the final interview scheduled for the 13th May 2020. Julian Baust is in his third term the Governors are asked to ratify his appointment for the second year of his term. Peter Jones has completed his first term as a part time clinical and research focussed NED consequently Governor’s are asked to ratify his second term. Please note he carries out the role unremunerated.

4.

RECOMMENDATIONS

The council of Governors is asked to take note of this report and ratify the following:

• The appointment of Non-executive Director, Julian Baust for the second year of his term.

• The appointment of Non-executive Director, Peter Jones for his second term.

5. APPENDICIES

None.

Author: Julie Spence Title: Trust Chair Date: 9th April 2020

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Julie Spence - Non Executive Activity Log

Jan-20

Day AM PM Evening2 Emails and correspondence

5 Emails and correspondence


9 Emails and Correspondence


14 Mtg Lead Governor: Mtg Trust secretary Mtg CE: Mtg Trust Secretary& Director QI

15 Interviews Re Consultant.

1617 Mtg re: Prisons initiative Cancelled mtg NHSE : Reverse Mentoring


20 Appraisals Benneyworth,Hindmarch,Turral App: Single. 1:1 Gerard Newnham Director

21 Clinical Exceelence Awards Panel

22 Visit to MAGPAS Prepare Board Development

23 Board Development Board Development

24 Appraisal: Hamilton&Lucas

27 Mtg Judge Business School

28 Prep for Board of Directors

29 Board of Directors Board of Directors Memorial dinner at Judge Business School

30 STP Private & Public meeting

31 Meeting Astra Zeneca Appraisal Jones & Baust Emails and Correspondence

Month Feb-20

Day AM PM Evening4 Meeting Lead Governor Emails and Correspondence

5 Regional Chairs Event @ Granta Park

67 Cambridgeshire Acre Cambridgeshire Events


1112 Reverse Mentoring NED recruitment meeting Emails and Correspondence

13 Injured Jockey’s Fund re Mental Health Governor/NED development session

14 Mtg CEO Emails and Correspondence

17 Visit Maple Ward Emails and Correspondence

18 Meeting Cambridge Ahead

20 Consultant interviews




Month Mar-20

Day AM PM Evening2 Emails and Correspondence Mandatory trg : Fire/safety/conflict res

3 Visit the Croft with Rowena Harvey

4 Mtg Lead Governor : Mtg Director Ops Director of Nursing interviews


6 Institute of Sustainability Leadership Pride Awards


11 Prep Wellbeing of Women Emails and Correspondence

12 Wellbeing of Women Wellbeing of Women Event

16 My appraisal with SID & Lead Governor Spirituality Forum

17 Teams mtg re Cambridge 2030 Emails and Correspondence

18 STP conference call

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19 Call re CCF Coronavirus Fund Mtg Wendy Scott Earle & PB adults team Call CEO re feedback from Visit

20 Call CEO

22 Call CEO Emails and Correspondence

23 Call CEO


25 Call CEO Call with County Resilince Forum

26 National Confed Zoom mtg: Call CEO Emails and Correspondence

27 Call CEO Call Trust Secretary


31 Call CEO Call Trust Secretary Emails and Correspondence

Month Apr-20

Day AM PM Evening1 MSTeams Public Board MS Teams Private Board

2Nat Confed Zoom Mtg:face time Mrs Daber Ask Tracy

4 Call Trust Secretary Emails and Correspondence

56 Radio interview Radio Cambridgeshire

7 Zoom Heathwatch Chair Call Trust Secretary Emails and Correspondence

8 Zoom staff Exit Interview: Call CEO Governor MTeams meeting

9 Nat Confed ZoomMtg : NED shortlisting NOMCO: Ask Tracy:NED weekly update STP chairs: Lead Governor mtg

10 Call CEO COG report

11 Call Andy Burrows Emails and Correspondence

12Call CPFT Comms:writing message to staff

14 Call CEO & Call Trust Secretary

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Month: Jan-20

AM PM EVENING3rd SFI review10th A&A prep12th A&A prep A&A prep16th A&A meeting23rd Board dev Board dev24th Board prep25th Board prep26th Board prep Board prep27th28th Appraisal prep29th Board Board31st Appraisal

Month: Feb-20

AM PM EVENING3rd Mandatory training6th Service visit Service visit13th Ned / Gov dev21st B&P prep22nd B&P prep24th Board prep26th Food tasting B&P

Month: Mar-20

AM PM EVENING3rd Admin/IT4th5th Board Dev Board Dev6th AAC panel7th CFM prep10th Quality visit Quality visit11th CFM prep CFM prep19th Mandatory training Mandatory training30th Board prep31st Board prep

Julian Baust

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Name: Brian Benneyworth

Month: Jan-20

AM PM EVENING

1st Holiday

2nd Holiday

3rd Holiday

4th Holiday

5th Holiday

6th Holiday

7th Holiday

8th Holiday

9th Holiday

10th Holiday

11th Holiday

12th Holiday

13th Holiday

14th Holiday

19th Appraisal preparation

20th Appraisal with Julie Spence Preparation for Childrens JV Board

21st Meeting with Anna Gill (CCS) Childrens JV Board meeting

23rdMeeting with Dr Baker Glen/Board Development Board Development meeting

27th Reading Board papers

28th Attendance at Carers Programme Board Reading Board papers

29th Board meeting attendance Board meeting attendance


Month: Feb-20

AM PM EVENING

3rd Telecon with Anna Gill (CCS) Attendance at Mandatory Training Wood Green

4th

Service Visit - Newton Centre Huntingdon - Neuro Rehab

9th Holiday

10th Holiday

11th Holiday

12th Holiday

13th Holiday

14th Holiday

15th Holiday

16th Holiday

17th Holiday

18th Holiday

19th Holiday

25th Catch up call Rachel Gomm Reading QSG/B&P Papers Reading QSG/B&P Papers

26th Chairing QSG Committee Attendance at B&P meeting

28th Admin/Emails


Month: Mar-20

AM PM EVENING

4th Exec Director Interviews Exec Director Interviews

5thAttendance at Board development meeting Attendance at Board development meeting

23rdCall/catchupCaroline MacPherson Emails/Admin

24th

25thInterview with This Institute (Cam) - Research project

26th Service visit - Hollies ward (Cancelled)

31stBoard meeting conference call Prep/Reading for Board meeting Prep/Reading for Board meeting

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Mike Hindmarch - Non Executive Activity Log

Month Dec-19

Month Jan-20

Day AM PM Evening7 AAC agenda

14 AAC prep AAC prep

16 AAC incl meeting with BDO

18 Appraisal prep

20 Appraisal JS


25 Mandatory training online B&P prep

26 B&P

27 AAC draft minutes Board prep

29 Board Meeting Board Meeting

30 STP meeting

31

Month Feb-20

Day AM PM Evening3 Mandatory Training

5 AAC final minutes

13 Joint NED/Governors

14 NHS audit chairs teleconference

19 Service Visit Personality disorders

25 B& P prep B&P prep

26 B&P

28 BDO seminar

Month Mar-20

Day Column1 Column2 Column35 Board Development Board Development

9 emails & admin

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Jo Lucas - Non Executive Activity Log

Month Jan-20

Day AM PM Evening3 Calls and emails follow up

10 Reverse mentoring meeting Writing up reverse mentoring

15 Springbank Service visit Writing up visit

16 Reverse mentoring meeting

20 Reading and information collecting Chair appraisal

Completing personal appraisal

22 LWLW meeting

23 Board development Board development

24 AT meeting Appraisal meeting

27 Reading board papers Reading board papers

29 Board meeting Board meeting

30 Meeting AS

Month Feb-20

Day AM PM Evening7 Reverse mentoring final meeting Completing RM evaluation

12 Prof P Jones meeting

13 Servcie visit Peterborough Joint NED Governor development

19 Call with MM re Chair appraisal

20 Reading QS&G papers Reading QS&G

26 QS&G Meeting Food tasting

28 AT Meeting

Month Mar-20

Day AM PM Evening4 Follow up food tasting

5 Board development day Board development day

6 KG reviewing Chair appraisal information collection

78 Head2Toe event Head 2Toe event

10 Reading charitable funds papers

12 Charitable Funds

16 Chairs appraisal meeting and final write up

20 AT meeting cancelled due to lock down

28 Reading Board papers

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Month: Feb-20

AM PM EVENING

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th Coroner’s Inquest Coroner’s Inquest

12th

13th

14th

15th

16th

17th

18th

19th

20th Read QSG papers Read QSG papers

21st

22nd Read B&P papers Read B&P papers

23rd

24th

25th

26th QSG meeting B&P meeting

27th

28th

29th

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Geoff Turral - Non Executive Activity Log

Month Jan-20

Day AM PM Evening12 Appraisal Prep14 Audit & Assurance prep 16 AAC Travel Audit & Assurance Committee20 Appraisal23 Board Development Board Development26 Board prep Board prep29 Public Board Public Board

Month Feb-20

Day AM PM Evening13 Governor Development Session22 QSG Preparation23 QSG Preparation24 B&P Preparation25 B&P Preparation26 QSG Committee Business & Performance Committee

Month Mar-20

Day AM PM Evening5 Board Development Board Development

17 B&P Committee Board Report B&P Committee Board Report30 Board Meeting Prep Board Meeting Prep

Month Apr-20

Day AM PM Evening1 Board Meeting7 Combined QSG BPC Planning

12 AAC Prep 13 AAC Prep1415 Audit & Assurance Committee

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of 5

COUNCIL OF GOVERNORS MEETING

Agenda Item: 5

Subject: Chief Executive’s Report

Date of Meeting:

Thursday 23rd April 2020

Author:

Tracy Dowling, Chief Executive

Responsible Lead:


Lead Director:


Purpose (please mark in bold)

TO NOTE INFORMATION DECISION APPROVAL RATIFY

CQC Key Lines of Enquiry (please mark in bold)

SAFE EFFECTIVE CARING RESPONSIVE WELL-LED

Link to the Trust’s strategic goals (please mark in bold)

DELIVER THE BEST

CARE

INNOVATION IN



IMPROVED WORKING

EXPERIENCE


bold, and explain)

FINANCIAL

LEGAL ENGAGEMENT PARTNERSHIP

WORKING

The report informs the Council of Governors of key areas of Trust activity, partnership working and engagement focussed on the Trust response to the Covid-19 pandemic.

Confidentiality/ Freedom of Information status:

Public Report

Committees/ groups where this has been presented before:

N/A

Committees/ groups where this should next be considered:

N/A

EXECUTIVE SUMMARY:

This report summarises key activities undertaken since the last report to the Council of Governors, and specifically informs the Council of Governors of the work of the Trust in response to the Covid-19 pandemic.

Recommendations: The Council of Governors is asked to note the contents of the Report.

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CHIEF EXECUTIVE’S REPORT

1.

Introduction / Background

This report updates the Council of Governors key activities undertaken by the Chief Executive since the last report. The report focusses on the Trust response to the Covid-19 pandemic.

2.

Report

2.1

Response to Covid-19 Pandemic A national level 4 incident has been declared and has now been in operation for six weeks. The Trust has responded by entering into full incident command and control status. Governors are updated weekly by the Chair, following the CEO and non-executive director Friday update. Governors are also invited to join the weekly ‘Talk to Tracy’ Live stream via teams where the ‘chat’ function can also be used to ask questions. At the time of writing this report I am sad to report that there has been one patient death in the Trust. As reported on our website, this was a 44 year old woman who had underlying health conditions. Our thoughts and condolences are with her family at this sad time. Across the trust to date we have had a total of 17 cases. Currently there are 9 Covid-19 positive cases in our care; 3 in mental health beds and 6 in physical health beds. A verbal update will be given in the meeting with the latest figures. Staff absence in total is running at about 15% with 11.5% Covid related. Most of this is as a result of self isolating. Many of these staff are working from home. There are very small numbers of confirmed cases amongst our staff. This number will increase now that staff testing is in place. The response of staff to the incident has been incredible. These are challenging times and it is understandable that staff are anxious and fearful for their own safety. However there has been an overwhelming willingness to be flexible, adaptable and innovative to ensure that we can look after those who need our care. The reality though is that we have needed to prioritise essential services and vulnerable patients for the coming weeks to be able to flex staffing and respond to the impact of changing demand as a result of Covid-19 cases presenting in our care; and also the impact on our workforce as a result of contracting Covid-19, experiencing Covid-19 type symptoms with the need to then self-isolate. Highlights of our response include: Incident management

• Incident Control Centre 8am to 8pm 7 days per week

• Bronze, Silver, Gold command structure in place

• System Gold chaired by CCG on a daily basis

• System Gold (CCG AO) co-chair of Local Resilience Forum (LRF)

• Regular internal meeting structure and handover arrangements in place

• Weekly review and adaptation to continuously improve Service Continuity Planning

• Every service and clinical directorate has produced a plan to identify essential services and services that would reduce / cease in response to either demand pressures and / or staffing reductions

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• Critical services include acute mental health in-patient, crisis and first response services; clinics where administration of medicines requires hands on care; community based physical health services.

• Video and virtual clinics are in place and the trust is rolling out a software package called Attend Anywhere to support virtual clinics. This is part of a national procurement.

• The trust is required to lead establishment of a Hospital Discharge Service to enable discharges 7 days a week 8am to 8pm within 3 hours of the discharge decision. This is in place and hospital bed occupancy is running at approximately 50%.

• All services have received PPE for the patients they are likely to encounter. PPE is available and is being used in line with national guidance.

• Plans are in place for isolation of Covid-19 suspected or positive patients where this is a practical response. This is not always the preferred course of action as there is risk in moving Covid-19 positive patients across the Trust. This is reviewed on a case by case basis.

• Training for staff groups and wards in management of patients with respiratory symptoms has been completed.

• Infection Control and Prevention (IPC) are providing advice to all clinical areas including ‘fit-checking’ for FFP3 masks which are worn during resuscitation.

• A ‘clinical cell’ has formed to advise Incident Control on clinical matters and to support clinical staff with complex decision making. An ethical cell has also been formed, chaired by Professor Peter Jones, to advise the clinical cell and the Trust on decisions which require ethics considerations

Social distancing, staff isolation and working from home

• Arrangements are in place for staff who are unwell or needing to self-isolate in line with national directions

• As many staff as possible are being enabled to work from home. This includes administrative and back office staff, and clinical staff who can consult with patients through digital means.

• Staff bases and places of work are operating social distancing to keep staff safe

• Messages to staff are sent daily vis staff News, all staff emails, Covid-19 posters and noticeboards to reinforce these messages

• Additional technology is being procured and all staff have been migrated to Office 365 to maximise home working.

• Staff notices regarding changes to terms and conditions, pay etc have been sent through daily staff news

• Our union representatives are working closely with us to ensure that we are hearing and able to address concerns of staff groups

PPE and Staff Testing

• At the time of writing we have enough supplies of PPE and guidance for its appropriate use in line with current national recommendations

• Staff testing for staff in self isolation, or staff who are unwell is now in place for staff or NHS family members. The tests need to be completed with days 1-3 of commencement of symptoms; day 5 at the latest. This should help staff who do not have a Covid-19 related cause to symptoms to return to work earlier than the current 14 days

Staff Health and Wellbeing

• HR guidance and advice is issued as this develops

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• Staff health and wellbeing is our top priority as we need our staff to be well to look after our patients. We have set up a Trust phone line for staff in addition to the national line

• All national advice is being implemented in full

• Staff are doing a tremendous job in challenging and extraordinary circumstances; we are recording all their great support and innovations in the ‘Spirit of CPFT’ page on our website

Patient and Staff Visiting

• This has been stopped in line with national guidance; other than in exceptional circumstances and at the discretion of the ward manager.

• We have stopped staff visits to clinical areas as reducing footfall has a significant impact on viral transmission. We are undertaking virtual visits instead.

Risk and areas of expected challenge

• A Covid-19 risk register has been developed and is reviewed formally each Monday as part of incident governance review.

Sustaining the response and recovery planning

• It is expected that the NHS may need to plan to respond to Covid-19 cases for up to 18 months. We are now exploring what this means for our services; how we would run Covid and non Covid services in parallel to reduce viral transmission.

• We are currently considering how we will model and respond to the expected significant mental health impact of this pandemic as this will be a long-term impact

• We are also working with the Judge Institute to assess what innovations and new ways of working we want to retain for the longer term. There have been many opportunities and changes to how we work and how we provide services that have been implemented incredibly quickly, and many of these we will want to retain.

2.2

STP and development of the local response to the NHS Long Term Plan (LTP)

The STP has paused most system wide activities. Only those activities that support the Covid-19 response are continuing, with the projects focussed accordingly. This pertains especially to the digital workstream and the human resources workstreams as both are crucial for the Covid-19 response.

2.3

Developing the Organisational Culture (OD) – Good to Great

Whilst formal work to develop further the Trust vision and strategy has paused whilst all staff focus their attentions to the Covid-19 response, we are continuing to ensure that the principles of value based behaviours, restorative just culture and staff health and wellbeing are especially prominent in our response.

2.4

Development of exemplar models for development of community MH

The mental health exemplar has paused given the attention of staff on frontline service delivery. The development of the online website to collate resources for the public to access to support their mental health and wellbeing is continuing to be developed given the urgency of need currently. We are hopeful that we will be able to recommence the exemplar in the near future to optimise our mental health response to the impacts of Covid-19.

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2.5

Cambridge Children’s Hospital

A meeting was held on 14th April 2020 of the Joint Investment Committee of DHSC and NHS E & I to review the Strategic Outline Case (SOC) for the Cambridge Children’s Hospital. I am thrilled to report that we received approval to progress to Outline Business Case (OBC). Work continues across both Trusts and with the University of Cambridge to develop the case for the Cambridge Children’s Hospital, as far as is possible given the engagement restrictions currently in place.

2.6

Executive Director Appointments

Rachel Gomm has been appointed substantively as Director of Nursing, AHPs and Quality.

2.7

Communications Update

Since moving to command and control, the Communications Team has provided an extended service including longer hours 8am-8pm, and weekend cover to ensure regular and timely communications. A number of additional internal channels have been put in place including; a daily staff update; a new dedicated Covid-19 microsite for staff information and guidance; a suite of materials including posters; a dedicated social media campaign; video blogs from the Chief Executive; and a #SpiritofCPFT community area online for staff to share tips, advice and support across Trust. A new charity appeal has also been launched to encourage donations, and local businesses are being approached to see how they could further support staff and patients. We are also actively applying for Emergency Funding opportunities to support the Trust and have received funds into Head2 Toe which we are using the support staff at this challenging time.

3.

Exceptions

There are no exceptions to report.

4.

Risks and Concerns

The key risk and concern is the Trust’s capacity to respond to the impact of the Covid-19 pandemic. Whilst full incident mobilisation is in place, there is potential that staff sickness and self-isolation, coupled with an increase in demand as a result of the pandemic, will mean that services will be temporarily restricted to essential only. Service modelling, plan and response review and learning from partner organisations across the country are informing our response.

5.

Assurance

The BAF and ORR are updated in view of any risks or concerns regarding the content of

this report.

6.

Recommendations

The Board is asked to note this report.

Tracy Dowling Chief Executive

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1

Agenda Item: 6

COUNCIL OF GOVERNORS MEETING

REPORT

Subject: Report and Recommendations of the Nominations Committee

Date of Meeting: Thursday 23rd April 2020

Author: Caroline Macpherson, Interim Trust Secretary

Responsible Lead: Keith Grimwade, Lead Governor

Lead Director: Julie Spence, Trust Chair


TO NOTE INFORMATION RECOMMENDATION RATIFY

CQC Key Lines of Enquiry (please mark in

bold) SAFE EFFECTIVE CARING RESPONSIVE

WELL-LED

Link to the Trust’s strategic goals (please

mark in bold)

DELIVER THE BEST

CARE

INNOVATION IN HEALTHCARE &

RESEARCH


IMPROVED WORKING

EXPERIENCE


bold, and explain)


WORKING

-


This is a public report


-


Board of Directors, 21st May 2020 (as part of Chairs Report)

EXECUTIVE SUMMARY:

This report provides a brief overview of key business and associated recommendations from, the Nomination Committee’s held on Thursday 9th April 2020. It draws attention to matters for consideration at its next bi-annual meeting on 3rd December 2020. The Council of Governors is asked to note that a report in respect of the Trust Chair’s Annual Appraisal is appended to this report.

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2

REPORT AND RECOMMENDATIONS OF THE NOMINATIONS COMMITTEE

1.

Non-Executive Directors

1.1

1.2

The Nominations Committee met on Thursday 9th April 2020 and makes the following update and recommendations to the Council of Governors, prior to its next bi-annual meeting of 3rd December 2020. Re-Appointment of Non-Executive Directors (NED)

• Julian Baust, Deputy Trust Chair and Non-Executive Director finishes the first year of his third term in April 2020. In accordance with Clause 26.4 of the Trust Constitution, the Council of Governors are asked to ratify the appointment of Julian’s second year of his third term on an annual basis. - Term 1: April 2013-2016 - Term 2: April 2016-2019 - Term 3 – Year 1: April 2019-2020 - Term 3 – Year 2: April 2020-2021 – for ratification.

• Jo Lucas, Senior Independent Director and Non-Executive Director finishes her second three-year term in October 2020. In accordance with Clause 26.4 of the Trust Constitution, the Council of Governors are asked to ratify the appointment of Jo’s first year of her third term on an annual basis. - Term 1: October 2014-2017 - Term 2: October 2017-2020 - Term 3 – Year 1: October 2020-2021 – for ratification.

• Peter Jones, Advisory Non-Executive Director finished his first three-year term at the end of March 2020. The Council of Governors are asked to ratify the appointment of Peter’s unremunerated advisory NED role for a second three-year term. - Term 1: March 2017-2020 - Term 2: March 2020-2023 – for ratification.

Non-Executive Director Recruitment

• Angela Single, Advisory and Non-Voting NED has completed her one-year advisory NED role and has now left the Trust.

• Sarah Hamilton, Non-Executive Director was allocating three days to the Trust per month, but continuously struggled to dedicate time to the Trust Board and Board Sub-Committees. Consequently, Sarah resigned from her NED role at the end of February.

The Trust is actively engaged with the recruitment process to appoint a new Non-Executive Director. Engagement of Inclusive Boards, an external recruitment agency has proven incredibly helpful and positive. There has been a significant interest in the vacancy, with a long list of 27 candidates and short list of 10 candidates compiled. Shortlisting has been undertaken by the Nominations Committee who have expressed confidence that the Trust will be in a position to appoint a suitable candidate to the required criteria. Interviews will be held virtually on the 13th May 2020, comprising of a virtual stakeholder

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3

1.3

panel and virtual decision-making panel. Non-Executive Director Annual Appraisals Appraisal interviews and reports have been concluded for all NEDs for 2019/20 and objectives agreed for 2020/21. The concluding summary for each NED has been considered by the Nominations Committee. The NHS Foundation Trust Code of Corporate Governance provides that outcomes of annual evaluations for all Non-Executive Directors are reported to the Council of Governors. Assurance is provided, by the Nominations Committee, that a fair and robust process has been carried out, in order for outcomes of the appraisal process to be formally received and ratified. Appraisal summaries, including Trust Chair assessments have been added to individual NED self-assessments, filed accordingly within individual personnel files and retained by the Trust Secretariat.

2.

Trust Chair Annual Appraisal

The annual Trust Chair’s appraisal process for 2019/20 has been led and completed by Jo Lucas the Senior Independent Director (SID), and objectives agreed for 2020/21. The concluding summary has been overwhelmingly positive and considered by the Nominations Committee. The review process comprised a self-assessment and feedback from the Board of Directors, Council of Governors and external stakeholders prior to a review meeting with the SID and Lead Governor. The Nomination Committee agreed the outcome of the Trust Chair’s annual appraisal by the Senior Independent Director, and provides assurance to the Council of Governors that a fair and robust process has been carried out in order for the outcome of the appraisal process to be formally received and ratified. In line with national guidance and the Trust Constitution, the Council of Governors are asked to ratify the appointment of Julie’s first year of her third term, taking the next review term to April 2021. A report in respect of the Trust Chair’s Annual Appraisal is enclosed at Appendix 1.

3.

Governor Elections 2020/21

In line with the Trust Constitution, the annual Notice of Election was initially planned to be published on the 16th April with a declaration of results on the 15th June 2020. Considering current circumstances and restraints in respect of Covid-19, the Trust has explored options to delay the election process by a 6 month and one-year period, which would result in extending terms of office for governors due for re-election in 2020. Current legislation does not allow us to extend terms of office and states that the maximum term of office governors may hold is for a three-year period.

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4

The Committee is seeking advice from Civica Election Services, who support the Trust election process, but felt delaying the elections until September 2020 remains relatively soon and therefore suggests delaying elections until April 2021 is the best option at this time. Moving forward the Nominations Committee proposes that following April 2021 elections, the formal Trust election process could be scheduled on a staggered two and three-yearly cycle. As a result, this will simplify the process, align Governor terms of office, lighten administrative demands and save the Trust money.

4.

Items Approved by the Nominations Committee

The Nominations Committee noted and approved the following:

• Committee Cycle of Business 2020/21 – approved April 2020.

• Committee Terms of Reference 2020/21 – approved November 2019.

• Clarification of the requirement for skills in data analytics within the Board Skills Matrix.

• Amendments to individual Non-Executive Director Job Descriptions.

5.

Exceptions

None to note.

6.

Risks and Concerns

None to note.

7.

Recommendations

The Council of Governors is asked to:

(1) Note the content of this report. (2) Ratify the appointment of Julian Baust, NED, for a second year of his third term. (3) Ratify the appointment of Jo Lucas, SID, for the first year of her third term. (4) Ratify the appointment of Peter Jones, unremunerated Advisory NED, for a second

three-year term. (5) Ratify the appointment of Julie Spence, Trust Chair, for the first year of her third term.

8.

Appendices

Appendix 1 – Trust Chairs Annual Appraisal Report

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Chairs Appraisal Report 2020 Page 1 of 2

NOMINATIONS COMMITTEE

Agenda Item: 6.1

Subject: Trust Chair’s Annual Appraisal 2020

Date of Meeting: 9th April 2020

Author: Caroline Macpherson, Interim Trust Secretary

Responsible Lead: Jo Lucas, Senior Independent Director

Lead Director: Jo Lucas, Senior Independent Director




bold) SAFE EFFECTIVE CARING RESPONSIVE

WELL-LED


mark in bold)

DELIVER THE BEST

CARE

INNOVATION IN HEALTHCARE &

RESEARCH


IMPROVED WORKING

EXPERIENCE


bold, and explain)


WORKING

As set out in the report.


Report contains personal data relating to the Trust Chair’s performance and objectives which is likely to be exempt from disclosure under FOI.


-


Council of Governors, 23rd April 2020

EXECUTIVE SUMMARY:

In accordance with the requirements of the NHS Foundation Trust Code of Governance, the

Council of Governors has the responsibility for agreeing a process for evaluation of the Trust

Chair, Julie Spence, and Non-Executive Directors.

The Trust has agreed a process whereby the Senior Independent Director (SID), is responsible

for carrying out the Trust Chair’s appraisal, for the Nominations Committee to oversee this

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Chairs Appraisal Report 2020 Page 2 of 2

process on behalf of the Council of Governors and report to the Council of Governors as

appropriate.

The SID and Lead Governor undertook an appraisal interview with the Trust Chair on 23rd

March 2020. The SID’s summary is as follows:

‘The Chair's appraisal was carried out by the Senior Independent Director and the Lead

Governor seeking views from a wide variety of stakeholders and following the format suggested

by NHS/E. The consistent view was that the Chair has been a positive force notably around

corporate and strategic impact, communications and leadership. The Chair's performance in

representing the community CPFT serves, supporting the CEO and Board and partnership

working in the system was also commented on very favourably. The objectives set for 2019

were reviewed and new ones identified for 2020. It was noted that the Chair has completed two

terms of three years and can be appointed for yearly extensions, subject to performance

review, up to a maximum of three years. The Nominations Committee is confident that the

process has been carried out correctly and requests that the CoG approve its recommendation

that the Chair is re-appointed for a further year, subject to performance review.

The Committee is recommended to:

(1) APPROVE the outcome of the Trust Chair’s Annual Appraisal by the Senior Independent

Director, and

(2) Provide assurance to the Council of Governors that a fair and robust process has been

carried out, in order that the outcome of the appraisal process may be formally received and

ratified.

The Committee’s recommendations will be reported verbally at the Council of Governors

meeting on the 23rd April 2020.

Author: Caroline Macpherson

Title: Interim Trust Secretary

Date: 9th April 2020

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Agenda Item: 7

COUNCIL OF GOVERNEORS MEETING IN PUBLIC

REPORT

Subject: Business & Performance Committee Report

Date of Meeting: 26th February 2020

Author: Geoff Turral

Responsible Lead: Geoff Turral

Lead Director: Scott Haldane – Director of Finance




bold) SAFE EFFECTIVE CARING RESPONSIVE WELL-LED


mark in bold)

DELIVER THE BEST

CARE

INNOVATION IN



IMPROVED WORKING

EXPERIENCE


bold, and explain)


WORKING

As detailed in the report


This is a public Report


none


none

EXECUTIVE SUMMARY:

The request status for the agenda items for the 26th February 2020 Business & Performance Committee was as follows;

• 1 agenda item for approval

• 10 agenda items for information

• 5 discussion items

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2

Business & Committee Report

1. INTRODUCTION / BACKGROUND

The following Trust business and performance items were discussed, reviewed and, if requested, approved.

• Business development, commissioning and contracting,

• Reference costs

• Capital & Infrastructure Group minutes

• Digital Strategy Update, inc. One Vision

• Agency report

• Integrated Performance Report Development

• Financial Report

• Cycle of business

• Terms of reference - review

• Operational Risk Register & Board Assurance Framework

• Provisional agenda for next meeting

2. BODY OF REPORT

Issues of note for Board consideration Item 4 - Business development commissioning and contracting CQUIN National Schemes Quarter 3

• At-risk financial payments limited to CQUIN 7 (high impact actions to prevent hospital falls), with a partial award of £89k against the full value of £103,960

• The outcome of CQUIN 5 (mental health data) was pending at the time of the meeting, but expected to be paid in full.

CQUIN 2020/2021 CCG CQUIN schemes for 2020/2021 have been released

• 9 schemes applicable to CPFT services

• Mandated schemes increased to 8

• Discussions being held with CCG in line with contractual negotiations to agree final schemes for inclusion within 2020/21 contract.

• Contracts and Informatics teams have met to discuss potential risks associated with specific CQUIN requirements, to input into contract negotiation

Item 5 – Reference Costs Reference costs refers to the mechanism that enables NHS England (via NHS Digital) to make peer comparisons across Trusts, in respect of key cost drivers and business level outcomes.

• A reference cost above 100 indicates worse value for comparable service delivery relative to a Trust below 100.

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• CPFT FY19 Reference Cost Index (RCI) is 109 vs 95 for FY18

• CPFT Community Services is 123 for FY19 vs 116 for FY18

• Mental Health Services is 104 vs 84 for FY18

• There are FY18 factors which, to an extent, explain the shifts.

• However, the reality is that, at the commissioning and system level, CPFT is increased danger of being perceived as delivering relatively poor value versus peer Trusts (selected by NHS Digital)

• Clear requirement to understand differences both in measurement and operational delivery, to move CPFT RCI to acceptable levels.

Item 6 – Capital & Infrastructure Group Summary and Minutes The Committee noted the approved minutes of the Capital & Infrastructure Committee of October 2019 (held on 22nd October) The Committee noted the cancellation of the December 2019 Capital & Infrastructure Committee. Julian Baust (Non-executive Director) requested a presentation of the long-term Estates vision for the Trust, which will be scheduled for a future B&P Committee. Item 7 – Transformation Update Summary Discussion of this item was deferred to enable Gerard Newnham (on leave) to give his broader perspective on the wider transformation challenges and forward agenda in the April B&P Committee. 9 - Agency report The Committee noted the key results contained within the Agency Report for the month of June 2019 (M5)

• Agency spend in M9 (Dec 19) was £594k, against the NHS Improvement (NHSI) ‘agency ceiling’ of £645k

• YTD agency costs are 12% less than the YTD ceiling target, resulting in a ‘Use of Resources’ score of 1 for the Agency Metric

• Medical agency costs have increased by 54% compared to the same period in FY19/20

• Significant system working changes are proposed to bank arrangements.

• Intention is to more efficiently manage the agency market at system level.

• Proposal is to integrate 6 banks into 1

• Will require cross-system agreement on standards, pay-rates, etc. 10 – Integrated Performance Report Development

• The IPR covering the period to 31st December was reviewed.

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4

• The committee noted that activity within CPFT during the month of December 2019, two NHSI statutory indicators were not achieved, namely Mandated Access Targets and Data Quality Maturity Index.

• Positive results were reviewed in context both of NHSI statutory indicators and Model Trust comparative performance.

• The Committee noted the clear value both in the presentation of time-series data and statistical process control (SPC), enabling quicker and more complete understanding of underlying performance trends.

11 – Finance and Cost Improvement Programme (CIP) Performance Report

• The financial report covered the period to 31st January 2020 (Month 10)

• In-month position was £86k behind plan.

• The year to date position is ahead of plan by £1.592m

• Full PSF for the year to date has been earned, equating to £1.339m.

• CIP delivery is behind target by £2.594m in the year.

• M10 (Jan 2020) delivered an improvement in recurrent savings, but 66% of CIP delivery has been achieved through non-recurrent savings.

3. EXCEPTIONS

4. RISKS AND CONCERNS

5. ASSURANCE

6. RECOMMENDATIONS

The Council of Governors is asked to note the content of this report.

7. APPENDICES

Author: Geoff Turral

Title: Business & Performance Committee Chair

Date: 26th March 2020

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Dashboard - CPFT Integrated Performance Report CQC Key Lines of Enquiry -Organisational level: Trust 100.0% 4.8% 9.5% 21Reporting Period : January 2020 Key 66.7% 14.3% 14.3% 21Reviewing committee/meeting : Business and Performance CCG 88.9% 0.0% 11.1% 9Review lead : John Martin, Chief Operating Officer N - National 84.6% 0.0% 30.8% 13Next Review Date : 1st April 2020 T - Trust 92.9% 7.1% 14.3% 14 Version number : Jan-20 v5

Last updated :

Safe 2018-19 Outturn

Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Target Actual YTD

S01 % compliant QuIET Assessment data (Safe Elements) * * * * 80.2% 80.9% 84.0% 82.1% 86.9% 86.2% 86.2% 92.8% 91.3% 90.7% 92.0% 92.3% -S02 % of Inpatient with a Risk Assessment * * * * T 98.4% 99.4% 99.1% 99.4% 98.3% 98.0% 98.3% 99.1% 98.8% 99.4% 99.1% 100.0% 99.1% >95% 98.9%S03 Staff trained in Children Safeguarding * * * * CCG 92.6% 91.8% 92.6% 93.6% 93.6% 93.9% 94.2% 93.9% 92.5% 92.3% 91.5% 92.9% 91.9% >90% 91.9%S04 Staff trained in Adults Safeguarding * * * * CCG 98.0% 98.0% 98.0% 94.6% 98.1% 98.3% 97.9% 97.7% 96.9% 97.6% 97.8% 98.0% 98.0% >90% 98.0%S05 Safety thermometer * * CCG 90.0% 89.6% 89.6% 88.5% 86.6% 91.0% 87.9% 88.0% 84.8% 88.5% 84.5% 88.8% 88.2% >95% 87.7%

S06 Never events * * * * T 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

S07 HCAI Essential Steps * * * * T 92.3% 96.2% 96.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 100.0% 100.0% 100.0% 95.0% 99.6%

S08 CAS Safety Alerts Implemented Within Required Timescale * * * * T 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.3% 100.0% 92.3% 100.0% 100.0% 98.0%

S09 Safe Staffing Levels (Registered and Unregistered) * * T 102.5% 102.6% 102.5% 103.4% 102.7% 103.5% 102.8% 102.2% 101.2% 102.4% 103.2% 102.5% 104.0% 80.0% 104.0%S10 Safe Staffing Levels (Registered) * * T 98.5% 101.3% 98.5% 101.6% 101.2% 101.2% 101.0% 96.4% 99.2% 101.9% 101.3% 100.1% 101.6% 80.0% 101.6%S11 Safe Staffing Levels (Unregistered) * * T 106.1% 103.8% 106.1% 105.0% 104.1% 105.6% 104.4% 107.5% 103.1% 102.9% 104.9% 104.7% 106.1% 80.0% 106.1%S13 % Vacancy Rate * * * * T 8.4% 8.1% 8.4% 9.4% 9.2% 12.0% 11.4% 9.2% 9.5% 9.3% 8.6% 8.2% 9.4% <10% 9.4%

S14 % Sickness Rate * * * * T 4.6% 4.8% 4.1% 3.7% 3.9% 3.8% 3.9% 3.8% 4.1% 4.4% 4.7% 5.1% 5.2% <4.35% 4.3%S15 % Spend Temporary Staffing- Agency * * * * T 4.3% 4.4% 4.3% 4.0% 4.4% 4.5% 4.4% 4.3% 4.2% 4.2% 4.2% 3.9% 4.7% <=4% 4.7%

S16 % Spend Temporary Staffing- Bank * * * * T 4.8% 4.7% 4.8% 5.0% 5.8% 5.6% 4.8% 5.0% 4.9% 4.9% 4.8% 4.7% 4.2% <=4.6% 4.2%

S17 Number of Serious Incidents Recorded * * * * T 88 5 7 0 3 7 1 1 2 2 2 1 2 TBA 21

S18 Trust wide % Serious Incidents (reported to CCG) resolved within National timescales (Grade 2 - 60 days) * * * * T 100.0% 100.0% 100.0% 50.0% 67.0% 67.0% 86.0% 83.0% 100% 100% 100% 100% 100% 100% 80.6%

S19 Grade 3/4 Pressure Ulcers – attributable to CPFT * * * * T 4 0 0 0 0 0 0 0 0 1 0 0 TBA 1

S20 MRSA Bacteraemia, confirmed case attributable to the Trust * * * * CCG 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

S21 Clostridium difficile, confirmed case attributable to the Trust * * * * N 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

S23 Number of incidents of violence against staff * * * * N 77 63 71 56 72 65 79 65 44 71 96 104 723

S24 Number of Falls with Harm * * * * N 24 38 31 25 28 23 25 22 24 28 26 21 253

Effective 2018-19 Outturn


E01 % compliant QuIET Assessment data (Effective Elements) * * * * 83.2% 81.4% 84.7% 82.8% 85.7% 87.4% 89.2% 94.7% 90.6% 90.2% 88.0% 90.3% -E08 % Patients with a Cluster Score * * * T 92.2% 92.5% 92.2% 92.4% 92.1% 91.3% 91.3% 91.0% 91.1% 90.1% 90.1% 90.0% 90.3% =>95% 90.3%

E09 % Patients with a Cluster within Cluster Review Period * * * T 55.0% 55.5% 55.0% 54.4% 55.0% 54.5% 56.0% 54.9% 54.5% 52.5% 53.4% 52.1% 54.2% =>95% 54.2%

E10 Diagnosis recorded (% of Current referrals where Diagnosis recorded) * * * * T 83.3% 83.8% 83.3% 83.1% 83.2% 83.7% 83.7% 82.9% 82.8% 82.8% 82.8% 82.4% 82.3% =>95% 82.3%

E11 Psychological Wellbeing Service (PWS - previously known as IAPT) - Number of referrals * *CCG

16759 1375 1585 1378 1513 1413 1344 1332 1394 1457 1859 1128 16721406 per

month (1/20)

14490

E12 Psychological Wellbeing Service (PWS - previously known as IAPT)– patients entering treatment * *CCG

13525 970 1018 1085 1145 1122 1322 1350 1295 1744 1394 1038 14091406 per

month (1/20)

12904

E13 Proportion of People Completing Treatment who Move to Recovery (from IAPT minimum dataset) * * CCG 51.6% 50.6% 50.2% 51.4% 50.3% 51.8% 50.1% 50.2% 50.5% 48.1% 50.3% 42.7% 50.1% >50% 49.4%

E16 ASCOF(1E) – Proportion in Employment (18-69, CPA) * * * N 14.60% 14.40% 14.60% 14.1% 14.1% 13.8% 13.6% 13.0% 12.7% 12.4% 11.7% 11.3% 11.9% 4.5% 11.9%E17 ASCOF(1F) – Proportion in Settled Accommodation (18-69, CPA) * * * N 79.90% 79.90% 79.90% 80.4% 81.3% 81.3% 81.5% 81.3% 81.1% 81.7% 81.7% 81.8% 81.5% 75.0% 81.5%E18 Recording of Physical Health Checks for patients with SMI - Started (Inpatient & EIP only) * * * * T 94.7% 94.7% 95.2% 95.4% 94.9% 96.3% 95.9% 94.9% 94.9% 94.3% 93.5% 92.9% =>75% 92.9%

E19 Recording of Physical Health Checks for patients with SMI - Completed (6 Core items -Inpatient & EIP) * * * * T 66.9% 65.0% 65.4% 68.5% 67.3% 68.8% 68.3% 71.6% 71.0% 67.8% 65.0% 63.7% =>75% 63.7%

E20 CPA 7 Day Follow Up * * * N 95.8% 95.8% 95.3% 97.1% 96.3% 96.8% 95.7% 94.7% 95.1% 96.1% 98.9% 98.1% 97.3% >95% 96.7%E32 CPA 3 Day Follow Up * * * N 67.6% 73.6% 77.32% 72.9% 67.7% 78.23% 82.7% 91.3% 90.5% 86.5% >80% 78.8%

E21 Service User CPA review 12 months * * * N 95.3% 95.1% 95.3% 94.9% 96.5% 96.6% 95.2% 94.4% 93.1% 91.7% 94.1% 94.7% 94.8% >95% 94.8%

E22 % of Inpatients Physical Health check within 24 hrs admissions * * * * T 95.7% 95.0% 96.6% 97.5% 98.5% 92.5% 97.0% 95.3% 94.1% 95.8% 99.1% 94.5% 91.9% >95% 96.3%

E23 Use of Resources - Financial Indicator * N 1 2 1 NCA 3 2 2 2 2 2 2 2 1 <=2 1

E27 Staff Supervision - monthly compliance * * * * T 56.3% 43.0% 28.3% 74.9% 73.0% 71.5% 71.0% 67.2% 68.1% 67.3% 63.6% 55.0% 44.2% TBC 65.5%E28 Appraisals (% Complete) * * * * T 40.3% 35.3% 39.7% 45.9% 45.9%

E29 % Delayed Transfers of Care Mental Health * * * * N 1.9% 2.9% 2.1% 1.9% 3.4% 2.2% 1.0% 0.6% 0.9% 0.5% 0.6% 1.2% 0.4% <3.5% 1.3%

E30 % Delayed Transfers of Care Community Services * * T 13.5% 9.7% 12.9% 9.8% 12.6% 12.5% 8.8% 13.5% 9.2% 9.3% 13.6% 7.6% 11.2% - 10.8%

Caring2018-19 Outturn


C01 % compliant QuIET Assessment data (Caring Elements) * * * * 79.1% 76.6% 79.8% 83.4% 85.2% 83.8% 88.5% 88.1% 87.2% 83.8% 91.2% 82.4% -C02 Triangle of Care - Carers Mental Health services * * * T 63.1% 48.9% 63.1% 62.8% 65.5% 66.3% 66.8% 65.9% 66.3% 66.6% 66.2% 68.4% 69.1% 60% 69.1%C03 Triangle of Care - Carers Physical Health services * * T 55.5% 50.4% 55.5% 57.0% 57.9% 58.1% 58.8% 59.2% 59.9% 60.9% 61.0% 60.9% 61.2% 60% 61.2%C04 Patient food * * * T 64.7% 60.6% 66.3% 60.2% 63.7% 62.5% 63.6% 60.2% 57.5% 64.5% 61.7% 65.9% 69.1% 75% 62.9%C05 Patient Experience - Friends and Family Question (% that would Recommend trust) * * * * T 94.5% 95.6% 95.6% 96.1% 95.4% 96.2% 95.2% 96.5% 96.4% 96.3% 95.8% 96.3% 95.0% >60% 95.9%C06 Admission to Adult Facilities of Patients Who are Under 16 Years Old * * N 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C07 Staff Net Promoter Score (recommend Trust to Friends and Family as a place to work) reported Quarterly * * * * T 56.4% 56.4% 62.5% 65.3% 62.8% >60% 62.8%

C08 Staff Net Promoter Score (recommend Trust to Care for Friends and Family ) reported Quarterly * * * * T 71.5% 71.5% 74.8% 74.5% 74.1% >60% 74.5%C09 Mixed Sex Breaches (Number of effected people) * * N 0 0 0 0 0 0 5 0 0 0 0 0 0 0 5

Responsive 2018-19 Outturn


R01 % compliant QuIET Assessment data (Responsive Elements) * * * * 81.6% 76.2% 71.1% 79.6% 85.3% 73.7% 82.9% 92.0% 81.5% 80.7% 81.8% 80.0% -

R02 Proportion of complaints resolved in 30 days (Or agreed extended timeframe, due to complexity) * * * * T13.6% (3/22)

40% (6/5)

44.4% (4/9)

31.6% (6/19)

12.5% (2/16)

26.4% (9/34)

46.7% (7/15)

39.0% (3/13)

8.0% (2/25)

25.0% (2/8)

35.3% (6/17)

28.6% (4/14)

TBC 26.5%

R05 Average Complaints response time (working days) * * * * T 53 42 45 44 50 55 46 53 69 46 49 52 <30 50.9

R08 Out of Area placements Excluding Locked Rehab- Total including ( Female PICU ) - ( bed days ) * N 1703 117 143 137 94 166 160 72 51 14 27 42 31 794

R09 Out of Area placements - Inappropriate - ( bed days ) * N 554 26 44 8 0 0 0 0 0 0 2 10 21 41

R11 EIP Access Target - % waiting < 2 weeks * * N 92.2% 84.6% 100.0% 81.8% 95.0% 94.1% 100.0% 85.7% 90.1% 80.0% 100.0% 87.5% 100.0% 53% 93.6%

R12 CAMHS Full Waiting List - waiting for Assessment (First Appointment) - (% >18 weeks) * * CCG 4.6%5.0% (25)

4.6% (24)

7.1% (38)

8.7% (43) 9.8% (48) 12.8% (79) 14.8% (85) 14.8% (85) 12.5% (78)15.7% (112)

18.6% (129)

20.0% (142)

<=8% 20.0%

R13 CAMHS Full Waiting List - waiting for Treatment following Assessment (Second Apt) - (% >18 weeks) * * CCG 15.0%13.0% (106)

15.0% (124)

19.9% (169)

23.6% (186)

26.7% (213)

24.9% (224)

26.9% (231)

27.3% (246)

25.7% (240)

28.5% (292)

31.8% (324)

34.6% (365)

<=8% 34.6%

R14 Children and Young People Eating Disorders CYP ED (Urgent referrals seen in 7 days) * * N 90.9%100% (1/1)

100% (3/3)

50% (1/2)

50.0% (2/4)

75.0% (3/4)

100% (3/3)100% (1/1)

75.0% (3/4)

91.7% (11/12)

100% (3/3)100%

(13/13)90.9% (10/11)

>50% 82.0%

R15 Children and Young People Eating Disorders CYP ED (Routine referrals seen in 4 weeks) * * N 68.5%85.7% (6/7)

100% (11/11)

70.0% (7/10)

100% (11/11)

81.8% (9/11)

83.3% (10/12)

63.6% (4/7)

87.5% (7/8)

100% (1/1)

69.2% (9/13)

100% (1/1)

100% (1/1)

>50% 87.5%

R16 Waiting Time to Begin treatment (from IAPT minimum data set) Within 6 Weeks * * CCG 88.2% 79.6% 73.7% 70.8% 68.3% 66.0% 62.6% 59.6% 57.0% 55.3% 52.8% 62.8% 66.1% >75% 62.2%

R17 Waiting Time to Begin treatment (from IAPT minimum data set) Within 18 Weeks * * CCG 99.2% 99.5% 99.0% 99.3% 99.2% 97.5% 97.8% 96.6% 96.1% 96.4% 95.7% 96.1% 96.6% >95% 97.1%

R18 Number of New Complaints - Rate of written complaints per WTE * * * * N 0.39% 0.36% 0.47% 0.47%

R19 Proportion waiting 4 weeks at month end (RiO data) * * * * T 72.1% 68.5% 65.9% 65.8% 71.5% 65.8% 63.8% 64.8% 68.1% 66.5%

R20 Median wait for patients first appointment in month (in Days - RiO data) * * * * T 7 7 7 10 8 10 8 9 7 13

Well Led 2018-19 Outturn


W01 Coroner Schedule 5 Notices * * * * T 0 0 0 0 0 0 0 0 0 0 0 0 0 - 0

W02 Number of new legal claims * T 15 1 1 2 2 2 1 1 0 0 2 1 0 - 11

W03 % Compliance Overall Mandatory Training (core modules) * * * * T 94.2% 94.2% 94.2% 94.3% 95.1% 94.9% 94.7% 94.3% 93.4% 93.4% 94.1% 94.2% 94.3% =>90% 94.3%

W04 % Compliance - Mandatory Training for Role * * * * T 84.5% 82.5% 84.5% 86.5% 87.9% 88.6% 88.8% 89.2% 88.8% 89.2% 89.6% 89.4% 89.2% =>90% 89.2%

W05 % Compliance currently up to date with - Good Governance training * * * * T 95.8% 95.4% 95.8% 95.6% 96.3% 96.3% 96.3% 95.7% 95.1% 95.4% 95.6% 95.8% 95.9% =>95% 95.9%

W06 Cumulative turnover rate (12 month rolling) * * * * T 11.3% 11.0% 11.3% 11.4% 12.0% 12.1% 12.6% 12.5% 12.6% 12.6% 12.7% 12.7% 9.4% <10.5 9.4%

W07 Average Number of Weeks to fill a vacancy (in Weeks) * * * * T 11.5 11.3 11.5 11.6 10.8 10.2 10.2 11.6 12.7 11.9 10.1 11.4 10.9 <10 10.9

W08 Financial Efficiency - Deficit (Cumulative) * N £4,098k £561k £4,098k NCA £140k £185k £53k £15k £35k £64k £8k £184k £847K -1.6% £847K

W09 Financial Efficiency - Adverse variance (position against where we expected to be) * N £923k £3,141k £923k NCA £911k £1,117k £1,115k £1,206k £1,269k £1,433k £1,439k £1,677k £1,592K -1.6% £1,592K

W10 Cash position versus plan * T 106.4% 106.8% 106.4% 122.0% 127.9% 115.2% 131.3% 129.1% 136.8% 137.4% 145.8% 151.3% 150.9% >=100% 150.9%

W11 Capital Spend v plan ratings * T 51.5% 45.6% 51.5% 18.7% 48.5% 45.3% 87.9% 89.9% 100.8% 91.3% 94.5% 90.7% 85.3% <100% 85.3%

W12 Compliance with DSPT (Data Security & Protection) toolkit v2 * * * *CQC

Met 54% Met N/A N/A N/A 32% 34% 36% 38% 40% 60% 72% 100% by Yr End

72%

W15 Data Quality Maturity Index (DQMI) - National figures release 3 months after submission * N 92.2% 89.0% 91.6% 91.6% 91.8% 92.0% 95.6% 97.1% 97.0% =>95% 97.0%

W16 Mental Health Services Data Set (MHSDS) - National figures release 3 months after submission * * N 87.5% 84.7% 88.9% 88.9% 89.3% 92.6% 98.2% 98.5% 98.3% =>95% 98.3%

W17 Community Services Data Set (CSDS) - National figures release 3 months after submission * * * N 97.2% 97.2% 97.3% 97.4% 97.6% 87.1% 87.0% 92.6% 92.8% =>95% 92.8%

W18 Improving Access to Psychological Therapies (IAPT) - National figures release 3 months after submission * * N 98.0% 98.1% 98.0% 98.4% 98.4% 98.4% 98.5% 98.4% 98.6% =>95% 98.6%

Ref: General Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Target Actual YTDG01 % compliant QuIET Assessment data - Overall Score * * * * 80.2% 78.1% 82.0% 80.9% 85.4% 84.0% 86.7% 90.7% 89.0% 86.8% 87.8% 86.8% -

TrustAdults

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easure Type 18/02/2020 14:02

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Caring Responsive

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SPC Graphs Grouped by - Key Lines Of EnquirySafe

75%

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100%

Feb

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-18

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r-1

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S05 - Safety thermometer

50%

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S07 - HCAI Essential Steps

0%

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S13 - Vacancy Rate

0%

1%

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4%

5%

6%F

eb

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S14 - % Sickness Rate

0%1%2%3%4%5%6%7%

Feb

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S15 - % Spend Temporary Staffing -Agency

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-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-19

De

c-19

Jan

-20

S16 % Spend Temporary staffing - Bank

02468

101214

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-19

De

c-19

Jan

-20

S17 Number of Serious incidents recorded

92%

94%

96%

98%

100%

102%

Fe

b-1

8

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

S02 - % of Inpatient with a Risk Assessment

of 68

Effective

86%

88%

90%

92%

94%

96%

98%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-19

De

c-19

Jan

-20

E08 % Patients with a Cluster Score

0%

20%

40%

60%

80%

100%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

E09 % Patients with a Cluster Score (within Review period)

75%

80%

85%

90%

95%

100%

Feb

-18

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

E10 Diagnosis recorded

0

500

1,000

1,500

2,000

2,500

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

E11 Psychological Wellbeing Service - Number of referrals

0

500

1,000

1,500

2,000

Feb

-18

Mar

-18

Ap

r-18

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Mar

-19

Ap

r-19

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

E12 Psychological Wellbeing Service - patients entering treatment

0%

10%

20%

30%

40%

50%

60%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

E13 Proportion of People Completing Treatment who Move to Recovery

0%

5%

10%

15%

20%

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-1

8

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-19

De

c-19

Jan

-20

E16 Proportion in Employment (18-69, CPA)

70%72%74%76%78%80%82%84%

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-1

8

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-19

De

c-19

Jan

-20

E17 Proportion in Settled Accommodation (18-69, CPA)

90%91%92%93%94%95%96%97%

Fe

b-1

8

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Ja

n-1

9

Fe

b-1

9

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Ja

n-2

0

E18 Recording of Physical Health Checks for patients with SMI - Started (Inpatient & EIP only)

60%62%64%66%68%70%72%74%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-19

De

c-19

Jan

-20

E19 Recording of Physical Health Checks for patients with SMI - Completed (6 Core items - Inpatient & EIP)

85%

90%

95%

100%

105%

Fe

b-1

8

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

Dec

-19

Jan

-20

E20 CPA 7 Day Follow Up

88%

90%

92%

94%

96%

98%

Fe

b-1

8

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Se

p-1

8

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Se

p-1

9

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

E21 Service User CPA review 12 months

85%

90%

95%

100%

105%

Fe

b-1

8

Ma

r-1

8

Ap

r-1

8

May

-18

Jun

-18

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-1

9

May

-19

Jun

-19

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

Dec

-19

Jan

-20

E22 % of Inpatients Physical Health check within 24 hrs admissions

-1%

0%

1%

2%

3%

4%

5%

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

E29 - % Delayed Transfers of Care Mental Health)

0%

5%

10%

15%

20%

25%

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-1

8

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-19

De

c-19

Jan

-20

E30 - % Delayed Transfers of Care Community Services

0%

20%

40%

60%

80%

100%

Fe

b-1

8

Ma

r-18

Ap

r-1

8

May

-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

De

c-1

8

Jan

-19

Fe

b-1

9

Ma

r-19

Ap

r-1

9

May

-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

De

c-1

9

Jan

-20

E27 Staff Supervision - monthly compliance

of 68

Caring

Responsive

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

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

C03 - % Triangle of Care - Carers Physical Health Service

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

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-19

De

c-19

Jan

-20

C02 - % Triangle of Care - Mental Health Service

0%20%40%60%80%

100%120%140%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

R11 EIP Access Target

0%

5%

10%

15%

20%

25%F

eb-1

8

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-19

De

c-19

Jan

-20

R12 CAMHS waiting for Assessment

0%5%

10%15%20%25%30%35%40%

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-18

Ju

n-1

8

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-19

Ju

n-1

9

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

R13 CAMHS waiting for Treatment

0%20%40%60%80%

100%120%140%

Fe

b-1

8

Ma

r-18

Ap

r-1

8

May

-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

De

c-1

8

Jan

-19

Fe

b-1

9

Ma

r-19

Ap

r-1

9

May

-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

De

c-1

9

Jan

-20

R15 Children & Young People Eating Disorders

0%

20%

40%

60%

80%

100%

120%

Fe

b-1

8

Ma

r-18

Ap

r-1

8

May

-18

Jun

-18

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-19

Ap

r-1

9

May

-19

Jun

-19

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

Dec

-19

Jan

-20

R16 Waiting Time to Begin treatment Within 6 Weeks

92%

94%

96%

98%

100%

102%

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Ju

n-1

8

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

R17 Waiting Time to Begin treatment Within 18 Weeks

-20%

0%

20%

40%

60%

80%

Feb

-18

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

R02 - Proportion of complaints resolved in 30 days (Or agreed extended timeframe,

due to complexity)

0

1

2

3

4

5

6

Feb

-18

Ma

r-1

8

Ap

r-18

May

-…

Jun

-18

Jul-

18

Au

g-…

Sep

-18

Oc

t-18

No

v-…

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

May

-…

Jun

-19

Jul-

19

Au

g-…

Sep

-19

Oc

t-19

No

v-…

Dec

-19

Jan

-20

C09 Mixed Sex Breaches (Number of effected people)

0

20

40

60

80

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

R05 Average Complaints response time (working days)

0

50

100

150

200

250

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-1

8

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-19

De

c-19

Jan

-20

R08 Out of Area placements Excluding Locked Rehab- Total including ( Female

PICU ) - ( bed days )

0

50

100

150

200

250

Fe

b-1

8

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Ja

n-1

9

Fe

b-1

9

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Ja

n-2

0

R09 Out of Area placements -Inappropriate - ( bed days )

40%45%50%55%60%65%70%75%80%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-19

Jan

-20

C04 - % Satisfaction Patient Food

90%

92%

94%

96%

98%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

C05 - % Patient Experience - would recomend trust for treatment

of 68

Well Led

Positive (also shows where no data available)

Negative

Target Line (Red dash line) No rule triggered

Upper process limit (Top line) The Rules:

Mean (Middle line) Any single point outside the process limits.

Lower process limit (Bottom line) A run of 7 points above or below the mean (a shift), or a run of 7 points all

consecutively ascending or descending (a trend).

Points which fall outside the grey dotted lines (process limits) are unusual and should be investigated.

They represent a system which may be out of control.

When more than 7 sequential points fall above or below the mean that is unusual and may indicate a significant

change in process. This process is not in control. There is a run of points below the mean.

SPC Graph Key:

86%

88%

90%

92%

94%

96%

Fe

b-1

8

Ma

r-18

Ap

r-1

8

May

-18

Jun

-18

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

De

c-1

8

Jan

-19

Fe

b-1

9

Ma

r-19

Ap

r-1

9

May

-19

Jun

-19

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

De

c-1

9

Jan

-20

W03 - % Compliance Overall Mandatory Training (core modules)

65%

70%

75%

80%

85%

90%

95%

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

W04 - % Compliance - Mandatory Training for Role

94%94%95%95%96%96%97%97%

Fe

b-1

8

Mar

-18

Ap

r-1

8

Ma

y-1

8

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-18

De

c-18

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-19

De

c-19

Jan

-20

W05 - % Compliance currently up to date with - Good Governance training

0%2%4%6%8%

10%12%14%

Feb

-18

Mar

-18

Ap

r-1

8

Ma

y-18

Ju

n-1

8

Ju

l-18

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-18

De

c-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

Ma

y-19

Ju

n-1

9

Ju

l-19

Au

g-1

9

Se

p-1

9

Oct

-19

No

v-19

De

c-19

Jan

-20

W06 - Cumulative turnover rate (12 month rolling)

02468

101214

Fe

b-1

8

Ma

r-1

8

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

Dec

-19

Jan

-20

W07 Average Number of Weeks to fill a vacancy (in Weeks)

-£2,000-£1,000

£0£1,000£2,000£3,000£4,000£5,000

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oc

t-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oc

t-19

No

v-1

9

Dec

-19

Jan

-20

W08 Financial Efficiency - Deficit £K (Cumulative)

-£4,000

-£3,000

-£2,000

-£1,000

£0

£1,000

£2,000

Fe

b-1

8

Mar

-18

Ap

r-1

8

May

-18

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

De

c-1

8

Jan

-19

Fe

b-1

9

Mar

-19

Ap

r-1

9

May

-19

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

De

c-1

9

Jan

-20

W09 Financial Efficiency - Adverse variance £K (position against where we

expected to be)

0%

50%

100%

150%

200%

250%

300%

Feb

-18

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Ju

n-1

8

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

W10 - Cash position versus plan(Target >=90% & <=110%)

0%

20%

40%

60%

80%

100%

120%

Fe

b-1

8

Ma

r-18

Ap

r-1

8

May

-18

Jun

-18

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oc

t-1

8

No

v-1

8

Dec

-18

Jan

-19

Fe

b-1

9

Ma

r-19

Ap

r-1

9

May

-19

Jun

-19

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oc

t-1

9

No

v-1

9

Dec

-19

Jan

-20

W11 - Capital Spend v plan ratings (Target less than 100%)

Note: When calculating the Mean line missing data is not included in the calculation

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Agenda Item: 7.2

Subject: Summary Finance Report – Month 11

Date of Meeting:

Wednesday 1st April 2020

Author:

Michelle Barnes, Assistant Director of Finance

Responsible Lead:

Scott Haldane, Director of Finance

Lead Director:

Scott Haldane, Director of Finance



Link to CQC KLoE (please mark in bold)



mark in bold where applicable)

DELIVER THE BEST

CARE

INNOVATION IN



IMPROVED WORKING

EXPERIENCE




WORKING

Report on progress against financial plan for FY20

Confidentiality/ FoI status:


Business & Performance Committee. Board of Directors


Council of Governors

of 68

SUMMARY FINANCE REPORT

EXECUTIVE SUMMARY:

The attached report is a Summary Finance Report for Month 11, which shows the key data for this reporting period. The Summary Report highlights the following:-

• In-month position is a surplus of £0.884m against a planned surplus of £0.949m, a negative variance of £0.065m in the month.

• The year to date position is a surplus of £1.730m against a planned surplus of £0.226m, a positive variance of £1.505m. The variance includes the profit (£0.832m) on disposal of Vinery Road, which was planned to complete in March 2020. However, the site was sold during May 19, which is a contributing factor to the year to date position. Without this, the Trust would still be £0.673m ahead of plan.

• The forecast is to deliver the Control Total planned surplus of £1.053m (excluding profit on disposal), which includes PSF of £1.745m.

• CIP plans are behind target by £2.587m in the year to date. The summarised CIP schedule can be found in Appendix 2 of the Finance Report.

• The Trust’s ‘Use of Resources Metric’ is a 1 at the end of Month 11 which is in line with the planned level of 1 at this stage.

of 68

Pride in our care

A member of Cambridge University Health Partners

Pride in our care

Summary Finance Report to 29thFebruary 2020 (Month 11)

25th March 2020

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Corporate Services Finance Report M11

Summary Finance Report to 29th February 2020

2

Contents:

Executive Summary

Appendix 1 – Use of Resources Metric Appendix 2 – Cost Improvement Programme

Scott Haldane

Director of Finance

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Executive Summary

3

Summary of PerformanceAt the end of period 11, the Trust is reporting a surplus of £1.730m, against a planned surplus of £0.226m. This financial performance generates a

performance of 1 against the Use of Resources Metric. The Vinery Road sale took place during May, which was ahead of plan. The Plan had been

phased to assume that this would not occur until March 2020. The planned and outturn positions also include a level of Provider Sustainability Fund

(PSF) income, having delivered against the Control Total for the year to date.

Key I&E issues:

• Income – ahead of Plan in the year to date (ytd) by £3.142m.

This includes additional income above Plan by £1.819m for

Education & Training in respect of the STP, LDA and SIF, and

R&D Income ahead of plan by £0.415m.

• Operating Expenditure – above Plan by £3.003m in the ytd.

Pay costs show an overall underspend in the ytd (£0.555m)

and Agency spend continues to be below the NHSI ‘ceiling’.

OATs spend continues to be a problem area, with £0.717m

overspend at end of M11.

Key Directorate issues:

• Clinical – overspend in the ytd of £1.949m, mainly due to

OATs overspend and unmet CIP. C&YP shows a YTD

underspend of £0.684m, whilst OPAC and A&S show

overspends of £0.592m and £2.040m respectively.

• Corporate – overspend of £1.004m in ytd, which is largely a

result of increased estates and IT costs.

Key Balance Sheet issues:

• Capex – Capital expenditure is behind Plan by £0.824m at

the end of month 11. This is an improvement on spend at the

same point in recent years. Forecast is to spend slightly less

than the original plan submission.

• Cash – cash held at the end of month 11 is ahead of Plan by

£17m, which is partly a result of cash received in relation to

the sale of Vinery Road and the additional PSF cash received

for 2018-19.

Use of Resources Metric:

• Performance against the Use of Resources Metric is a 1 for the period against a

planned 1. Further details in Appendix 1.

CIP:

• Under-delivery of £2.587m in the ytd – for further information please see Appendix

2. Work is ongoing with Directorates to try to convert existing non-recurrent

savings to recurrent, as well as to identify additional CIP schemes to bridge the

gap, and reduce any CIP carry forward target. Savings outside of the CIP plan

contribute to the overall Trust position.

A detailed Finance Report is provided to members of the Business and Performance

Committee on a monthly basis.

Summary Key Financial Performance Indicators

Month 11 & Year to date Plan Actual

Plan to

Date

Actual to

Date

£m £m £m £m £m £m

Income 18.461 19.328 0.867 204.141 207.282 3.142

Operating Expenditure (17.302) (18.289) (0.987) (201.610) (204.612) (3.003)

Financing (0.210) (0.154) 0.056 (2.306) (1.814) 0.491

Other gains/(losses)

including disposal of assets 0.000 0.000 0.000 0.000 0.875 0.875

Net Surplus/(deficit) 0.949 0.884 (0.065) 0.226 1.730 1.505

EBITDA 1.505 1.389 (0.116) 6.342 6.731 0.389

EBITDA % 8.15% 7.19% -0.96% 3.11% 3.25% 0.14%

I&E Surplus Margin % 5.14% 4.58% -0.57% 0.11% 0.83% 0.72%

Agency Spend (0.645) (0.656) (0.011) (7.095) (6.484) 0.611

Agency Spend % 4.7% 4.8% -0.1% 4.7% 4.3% 0.4%

Capex 0.672 0.646 (0.026) 6.081 5.257 (0.824)

Cash and Cash Equivalents 21.6 38.6 17.0

Cost Improvement Programme 0.584 0.488 (0.096) 7.688 5.101 (2.587)

Use of Resources 1 1

Month 11 Year to Date

Variance

Favourable

/ (Adverse)

Variance

Favourable

/ (Adverse)

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Use Of Resource Metric for CPFT

4

Appendix 1 – Use of Resources Metric (UoR)

The Use of Resources Metric is used to assess the financial performance of all NHS Provider Organisations. This includes a range of financial planning metrics,

including performance against the Agency ‘cap’ in the overall rating. The scoring is a range from 1 to 4, with 1 being the best performance.

The metrics and associated weightings are highlighted in Table 1, with the Trust’s performance highlighted in Table 2. Actual performance in Month 11 is ahead of

plan as a 1. The agency rating continues to score better than plan as spend remains lower than NHSI ceiling.

Table 1: Finance and use of resources metrics Table 2: CPFT Performance

Rating at Month 11 is a 1

Extract from Single Oversight Framework

The overall finance and use of resources score is a mean average of the scores of the

individual metrics under this theme, subject to any support needs being identified in value for

money – except that:

- if a provider scores 4 on any individual finance and use of resources metric, their overall

use of resources score is at least a 3 – i.e. cannot be a 1 or 2 – triggering a potential

support need

- if a provider has not agreed a control total, then where they are planning a deficit their

use of resources score will be at least 3 (i.e. it will be 3 or 4). Where they are planning a

surplus their use of resources score will be at least 2 (i.e. it will be 2, 3 or 4).

As we continue to develop a shared approach to use of resources with CQC we may seek to

revise the finance and use of resources metrics used in the Single Oversight Framework. If

we do so, we will consult as needed.

Finance and use of resources rating 03PLANYTD 03ACTYTDPlan Actual

Plan Actual

29/02/2020 29/02/2020

YTD YTD

Rating Rating

Capital service cover rating 2 2

Liquidity rating 1 1

I&E margin rating 2 2

I&E margin: distance from financial plan 1 1

Agency rating 1 1

Overall rating unrounded - 1.40

If unrounded score ends in 0.5 - 0.00

Plan risk ratings before overrides - 1

Plan risk ratings overrides:

Any ratings in table 6 with a score of 4 override -

if any 4s "trigger" will show here No Trigger No Trigger

Any ratings in table 6 with a score of 4 override -

maximum score override of 3 - 1

Control total override - Control total accepted Yes Yes

Control total override - Planned or Forecast

deficit No No

Control total override - Maximum score (0 = N/A) 0 0

Is Trust under financial special measures No No

Risk ratings after overrides 1 1

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Appendix 2 – Cost Improvement Plan Analysis

5

The year to date CIP position is a shortfall of

£2.587m against Plan.

The gross CIP target for FY20 is £8.9m (3.9%),

which includes a £2.4m target for turnover factor.

This latter element has been apportioned across

all Clinical and Corporate Directorates and is

expected to be delivered through vacancy

slippage.

The Clinical Directorates continue to identify CIP

savings through SLR meetings. Progress of their

CIP plans and trajectory timelines are presented

at PRE each month. The in-month CIP achieved

includes £690k of non-recurrent contingency, as

planned, to offset the additional £1.9m non-

recurrent target phased in Q4. Of the total savings

delivered YTD, 72% of this has been delivered

from non-recurrent savings.

Month11 Plan Identified

Schemes

(% of Plan)

Achieved

Recurrently

(% of Plan)

Achieved

non

recurrently

(% of Plan)

Total

Achieved

(% of

Plan)

Variance

against plan

(% of Plan)

In-month £1.217m £1,098k

90%

£143k12%

£1,081k89%

£1,224k101%

-£7k-1%

YTD £7.688m £6.522m

85%£1.445m

19%

£3.656m48%

£5.101m67%

£2.587m33%

CIP REPORT Month 11 FY20

Scheme

Annual Savings

Target Value (inc

Turnover Factor)

Target

Savings

YTD

Actual

savings

YTD

Recurrent

Actual

savings

YTD Non

Recurrent

Total

Savings

YTD

Variance

YTD Comments

Plans by Directorate

Adult & Specialist 2,240 2,053 352 156 508 -1,545

Older Peoples & Adults Community 2,217 2,032 978 1,054 2,032 -0

Childrens 1,307 1,198 82 1,117 1,198 -0

Corporate 1,580 1,448 33 639 672 -776

Non Recurrent opportunities 1,900 1,267 0 690 690 -577 Plan phased to deliver in Q4

CIP Risk Reserve -339 -311 311

TOTAL 8,905 7,688 1,445 3,656 5,101 -2,587

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1

Agenda Item: 7.3


REPORT

Subject: Freedom of Information (FOI) Update

Date of Meeting: 8 January 2020

Author: Carol Smith, Corporate Information Officer

Responsible Lead: Caroline Macpherson, Associate Director of Corporate Governance and

Trust Secretary (interim)

Lead Director: Kit Connick, Director of Corporate Affairs




bold) SAFE EFFECTIVE CARING RESPONSIVE WELL-LED


mark in bold)

DELIVER THE BEST

CARE

INNOVATION IN



IMPROVED WORKING

EXPERIENCE


bold, and explain)


WORKING

The Trust is obliged to respond to information requests submitted under the Freedom of Information Act.


The report is likely to be disclosable under FOI.



EXECUTIVE SUMMARY:

The Trust’s performance in responding to FOI requests is ‘business as usual’. The focus now is on moving the Trust from meeting the minimum requirements of the Freedom of Information Act 2000 to achieving best practice.

of 68

2

Freedom of Information (FOI) Update

1 INTRODUCTION / BACKGROUND

This report informs the Committee of activity between 1st April – 31st December 2019 related to the Freedom of Information Act 2000.

2 SUMMARY

Volume of Requests

As of 31 December 2019, the team had received 357 requests as opposed to 348 requests at the end of December 2018, an increase of 2.6%.

Teams dealing with requests, FY20 YTD

The data illustrates that the Trust Secretariat dealt with the highest number of FOI requests (79). This data is however, somewhat misleading as almost all of these were requests that were not applicable to CPFT, i.e. queries about maternity services, stats for

78 84 84

156179

266

317337 348 357

0

50

100

150

200

250

300

350

400

Q3 FY11 Q3 FY12 Q3 FY13 Q3 FY14 Q3 FY15 Q3 FY16 Q3 FY17 Q3 FY18 Q3 FY19 Q3 FY20

FY11-FY20 - Q3 Cumulative

79

5043

2923 20 18

0

10

20

30

40

50

60

70

80

90

Teams dealing with requests - FY20 YTD

of 68

3

A & E departments, etc. and so were dealt with quickly within the Secretariat and not forwarded to another team for response. In practical terms, the teams with the highest number of requests (and therefore volume of work) were Finance (50), followed by Information and Performance (43), Estates (29), TSS/Translation (23), ASMH Directorate (20), and I.T. (18). (The complete list of teams is available upon request.)

Percentage of FOI requests closed per regulations, delayed or outstanding, FY20 YTD

(to 31 December 2019)

A significant proportion (47.87%) of FOIs are answered within five days of the request being made and just over 53% of FOIs are answered in six days or less. Of those FOIs which breach the 20-day deadline, most of these are answered within 10 days of the requester being notified of the delay. Most of those FOIs which were overdue by more than 10 days were waiting on information from one team. The FOI response from this team has become a real issue, with one outstanding FOI now over 100 days overdue.

310, 87%

25, 7%

23, 6%

FOI response time FY20 (YTD)

Closed as per FOI regulations

Delayed

Outstanding

157

56

36

57

21

3 3 0 1 10

20

40

60

80

100

120

140

160

180

0-5 6-10 11-15 16-20 21-30 31-40 41-50 51-60 61-70 71-80

No

. of

FOIs

clo

sed

No. of days open

FY20 YTD

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4

Response Time – FY20 (YTD)

Dashboard The Dashboard for FY20 Q1-3 is available on the Trust website at https://www.cpft.nhs.uk/about-us/foi-requests.htm. For information, a copy of the dashboard is

appended to this report. New way of working At the last meeting it was requested that Richard Matt and Carol Smith meet to review the new process and see if there was a way to make it more workable. We have a meeting scheduled for 7th February to look at this.

EXCEPTIONS

Internal Reviews There have been six requests for internal reviews in FY20.

1. The requester was originally pointed to information published on the Trust website, but this unfortunately did not entirely meet the requested criteria. The review was undertaken by the Chief Executive. The decision following review was to provide more specific information than is published on the Trust website.

2. The request came in as part of a complaint and was already overdue by the time it was forwarded to FOI. The original response was refused under Section 12. The requester did not believe that gathering the data he requested would take over 18 hours. The review was undertaken by the Chief Executive. The decision following review was to uphold the original application of Section 12 and a more detailed explanation of the process required to extract the data he requested was provided.

3. An organisation requested updated IT infrastructure data that had been provided to them in years past. This was refused under Section 31 in line with the decision taken in March 2019 to withhold such information for security reasons. They asked for a review, stating their reasons for asking and their intended use for the information, and outlining how they would keep the data secure. The review was undertaken by the Chief Executive. The decision following review was to uphold the original decision to apply Section 31.

4. The request asked for cost of legal representation for inquests due to death in specified circumstances. The original response stated that we do not hold the information. Personal identifiable data is provided with invoices for verification but is then securely

0

10

20

30

40

50

60

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Response Time - FY20 YTD

Closed per FOI Delayed Outstanding Total

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https://www.cpft.nhs.uk/about-us/foi-requests.htm

5

destroyed. The requester challenged this claim, stating that we must have some record of what each invoice was for. After review and discussion with Finance, the original response was upheld.

5. The request asked about vending machines at CPFT and what snacks the machines hold, i.e. how many were under 150 calories, etc. It asked for five years’ worth of data. The original response stated that the Trust does not hold the information in a retrievable format, as information on vending machines is not held centrally. The requester has challenged this. The internal review response informed the requester that the vending machines were not owned/leased by the Trust, but supplied by the PFI’s soft FM provider.

6. The request was for a copy of the review carried out by the Trust in relation to the convicted killer Joanna Dennehy. The original response stated that the Trust did hold a serious incident review, but the document was being withheld under section 40(2) of the FOIA. The requester asked for an internal review, stating he believed that significant public interested outweighed the individual’s right to privacy in this instance. After discussion with Chess Denman, the decision was taken to uphold the original decision.

Learning from these reviews will be fed into future FOI requests and shared accordingly. Information Commissioner’s Office There has been no contact from the Information Commissioner’s Office with regard to FOIs submitted in FY20.

4.

RISKS AND CONCERNS

Responding to FOIs would not be achievable without the continuing co-operation of Trust teams to provide information to the Secretariat in a timely manner, which has at times created additional resources pressure on internal teams, particularly Estates, Information and Performance and Finance. The Trust Secretariat continues to work closely with these teams to identify and address capacity issues which have the potential to affect future performance. Confusion around recognition and handling of FOI requests The approved intranet pages were not uploaded immediately as Carol Smith was on annual leave. It did not seem helpful to direct people with questions to someone who was not available to assist. These pages will be uploaded to the intranet under Trust Secretariat as soon as editing rights are obtained to those pages.

5.

ASSURANCE

Awareness of the Freedom of Information Act is given within the Trust’s corporate induction programme and included as part of the good governance module. This is now an annual mandatory training requirement for staff which will raise overall awareness of the importance of FOI.

6.

RECOMMENDATIONS

The Committee is asked to:

(1) Note the report,

7.

APPENDICES

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6

• Appendix 1: FOI Performance Dashboard

Author: Carol Smith

Title: Corporate Information Officer

Date: 2 January 2020

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Agenda Item: 8

Subject:

Quality, Safety and Governance (QSG) Committee Summary Report

Date of Meeting:

Wednesday 23rd April 2020

Author:

Brian Benneyworth, Non-Executive Director

Responsible Lead:


Lead Director:


Report Purpose: (please mark in bold)

To Note Information Decision Approval Ratify

Link to CQC KLoE: (please mark in bold)

Safe Effective Caring Responsive Well-Led

Link to Trust Strategic Goals: (please mark in bold

where applicable)

DELIVER THE BEST

CARE

INNOVATION IN



IMPROVED WORKING

EXPERIENCE




WORKING

As detailed in the report.

Confidentiality / FoI status: Public Report


Board of Directors meeting

Committees / groups where this should next be considered:

N/A

QSG COMMITTEE SUMMARY REPORT

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EXECUTIVE SUMMARY:

This summary provides a brief overview to CPFT Governors. The QSG Committee met on 26th February 2020 and considered in detail the following papers:

1. Adult/Specialist self-harm update review

2. Quality and Safety Report

3. Freedom to Speak Up (Q3) Report

4. Clinical Audit report

5. Quality Improvement (QI) Update

6. Mental Health (MH) Social S75 Partnership Agreement Governance Board Report

7. Mental Health (MH) Law Compliance Report

8. Quality Strategy Report

9. Quality Accounts Report

10. Workforce Report

11. CQC Compliance Report

12. QSG Terms of Reference 20/21

13. Cycle of Business 20/21

14. Policy Ratification (34) in total

15. BAFF/ORR

16. Covid – 19 Verbal Update – For Assurance

1.

INTRODUCTION / BACKGROUND

The purpose of this report is to provide an update to the Council of Governors on activity undertaken and reported to the Quality, Safety and Governance Board Sub-Committee since the last activity update report presented in December 2019

2.

SUMMARY

The following highlights and exceptions are brought to the Council of Governors attention:

The Committee was assured on the following:

• The increased level of seclusion rates was attributable to a limited number of high acuity patients in the Croft, which has received recently a positive mental health review with regards its seclusion practices.

• Six Freedom to Speak Up (FTSU) Ambassadors have come forward to support the Trust’s FTSU Guardian including Dr Paul Hay.

• A new Adult Social Care model has been co-produced by social workers and was due for launch on 30th April 2020.

• There was positive movement across a number of staff survey results including disability adjustments and recommending the trust as a good place to work.

• Following a detailed discussion, the Committee was assured that the Trust’s Executive and Emergency Planning Team had a coordinated risk-based approach to tackle the Covid-19 challenge across the Trust.

The Chair and Committee were not yet fully assured with regards to:

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• The completion and failure to record the follow up actions on the Action Log, this issue has been taken forward and discussed with the Director of Corporate Affairs and the Trust Secretary.

• Capacity to support NICE guidelines was identified as an issue, this will obviously be impacted by current events, but the Committee will be following this up at the next full QSG meeting.

• There is a delay in getting the MH Social 75 Partnership Legal Agreement in place, due to performance monitoring queries, this is being followed up by the Committee. There was a significant overspend last year on Mental Health cost of care budgets last year, a deep dive exercise has been initiated to gain further understanding and future action to mitigate for this year.

• There were four overdue actions from the CQC Compliance report, the Committee asked for these to be followed up and resolved as a matter of urgency.

The Committee has requested further information as follows:

• The Committee requested an item to review increased acuity at the next full QSG meeting.

• Schedule of CQC Mental Health Compliance report at next full QSG meeting.

• Requested regular outside meeting updates on Covid-19 status.

• Follow up response requested on outcome of Mental Health cost of care budgets.

The Council of Governors is advised to note the following with regards to the current Covid-

19 affected position:

• An additional policy “Medical Gases” which has been ratified virtually outside of the meeting, in addition to the 34 stated in the last QSG meeting minutes.

3.

RISKS AND CONCERNS TO ESCALATE

Emerging Covid 19 risk planning.

4.

RECOMMENDATIONS

The Council of Governors is asked to note activity outlined within this report.

5.

APPENDICIES

None.

Author: Brian Benneyworth Date: 1st April 2020

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1

Agenda Item:


REPORT

Subject: Audit and Assurance Committee Report- January 2020

Date of Meeting: Thursday 23rd April 2020

Author: Derek McNally, Deputy Director of Finance

Responsible Lead: Mike Hindmarch, Non-Executive Director & Chair of AAC

Lead Director: Scott Haldane, Executive Director of Finance

Link to CQC KLoE (please mark in bold)



mark in bold where applicable)

DELIVER THE BEST

CARE

INNOVATION IN



IMPROVED WORKING

EXPERIENCE




WORKING

As set out in the report.


Summary from Audit and Assurance Committee January 2020 , Board of Directors meeting January 2020

Executive Summary: This report presents the key issues discussed by the Audit and Assurance Committee (AAC) at its meeting on 16th January 2020. The areas which the Committee wish to be brought to highlight include:

• Internal Audit and Local Counter Fraud Service (LCFS) Progress Report; • Annual Accounts Timetable; • Review of Standing Financial Instructions (SFI’s); • AAC Terms of Reference; • Dispensations to Waiver compliance with SFI’s; • Private Discussion with Internal and External Audit.

Audit and Assurance summary report

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2

1. INTRODUCTION / BACKGROUND

The purpose of this report is to highlight key issues discussed at the January meeting of the Committee which it is felt should be drawn to the Council of Governors attention. This Committee is a Sub-Committee of the Board established to review audit and assurance issues and performance for the Trust in accordance with the established terms of reference.

2. ITEMS DISCUSSED

The following highlights and exceptions are brought to the Council of Governors’ attention:

Internal Audit Progress Report The Committee considered the Internal Audit Progress Report at Quarter 3.

The Committee were assured with regards to:

• The progress made to catch up with the Internal Audit plan for the year; • The progress made in progressing recommendations in the year.

The Committee sought further assurance/information/actions with regards to:

● Engagement of the Trust Leadership Team (TLT) with Internal Audit. The AAC (Audit

and Assurance Committee) suggested BDO use TLT session on Planning for FY21 to

also provide training on how Internal Audit operates and can be used to add value to

the organisation; ● The progression of actions within the Patient Falls and the Complaints Reports be

reported via the Trusts QSG (Quality, Safety & Governance) Board sub Committee; ● Further consideration of the recommendations of the advisory Review of Internal

Controls on Agency. LCFS Progress Report The Committee received the LCFS Progress Report at Quarter 2.

The Committee were assured with regards to:

● The progress in delivering the LCFS plan for the year to date.

Annual Accounts Timetable The Committee received the timetable for completion of the Annual Accounts for FY20. The Committee noted that this will be the first year of completing the Accounts using the new Oracle system and the NHS Shared Business Services (SBS) closedown timetable and were assured that the national timetable will be met. The Committee also noted the one-day turnaround between the Audit Committee and the Trust Board in May for approval of the Annual Accounts which was brought to the attention of the Trust Board in January. Audit and Assurance Committee Review of SFI’s The Committee received the proposed amendments to the Trust’s SFI’s following the Annual Review.

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3

The Committee were assured with regards to the proposed amendments and requested that a clearer distinction be drawn between the Trusts Accounts and the Charity Accounts in the SFI’s. The Committee approved the amendments with this change incorporated and presented to the Trust Board for ratification in January. Audit Committee Terms of Reference The Committee reviewed its Terms of Reference for approval by the Trust Board. The Committee requested an amendment to include the requirement to always have at least one Executive Director in attendance at the Committee, which will normally be the Director of Finance. Dispensations to Waiver compliance with SFI’s The Committee received the report outlining agreements to waive SFI’s in Quarter 3. The Committee sought further assurance/information/actions with regards to:

● Ensuring a due diligence review is undertaken on IESO who provide online therapy

services in support of the PWS (Psychological Wellbeing Service) within the Trust;

● Requesting further information on the governance process within the STP on the

agreement to appoint CHIME as the supplier to support an STP Digital Boot camp.

Private Discussions with Internal and External Audit The Committee held a private discussion with both Internal and External audit as part of the annual audit cycle of business. Areas discussed included the current state of the market for External Audit in the Public Sector and relationships between Internal Auditors and Trust Leadership Team.

3. EXCEPTIONS

As noted above

4. RISKS AND CONCERNS

As set out in the main body of the report.

5. ASSURANCE

As noted above.

6. RECOMMENDATIONS

The Council of Governors is asked to note the contents of the report.

7. APPENDICES None

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4

Author: Derek McNally Title: Deputy Director of Finance Date: 17th January 2020

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