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Assembly of Governors General Meeting

TO BE HELD ON 16 MAY 2017 at 5.30 pm to 7.00 pm

DELTA HOUSE CAFE - DELTA HOUSE

A G E N D A

No: Item Purpose Lead Enclosure /verbal

1 Opening Matters

1.1 Declaration of Interest

1.2 Apologies for Absence

1.3 Minutes of the previous meeting For Approval

Enc. 1.3 3 - 12

1.4 Matters Arising not on the agenda

2 Matters Arising

2.1 Action Log For Information

Enc. 2.1 13 - 14

2.2 The role of the Equality and Inclusion Board

To Receive

J Cadman E Louis

Enc. 2.2 15 - 26

2.3 Appointment of Associate Non Executive Director

For Approval

J Newton Verbal

3 Other

3.1 Transforming Care Together Update For Information

T Taylor Verbal

3.2 Update from Integration Board To Receive

M Ingram Verbal

3.3 Governor Gauge: Outcome of Survey To Receive

A Green Enc. 3.3 27 - 32

3.4 Operational Performance of the Trust to 31st March 2017

To Receive

Enc. 3.4 33 - 36

3.5 Staff Survey 2016/17 To Receive

J Cadman Enc. 3.5 37 - 66

DATE AND TIME OF NEXT MEETING: The next meeting will be held on Tuesday, 18 July 2017 at 5.30 pm in

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Minutes of the Assembly of Governors General Meeting Held on Tuesday, 21 March 2017 at 5.30 pm

In Cygnet Suite - Quayside House Present: Joanna Newton (JN) (Chair) Chair Melvena Anderson (MA) Staff Governor, Planned Care MH Mary Bolland (MB) Public Governor - Wolverhampton

John Cash (JC) Sandwell - Public Governor Brian Chindendere (BC) Public Governor - Wolverhampton Phil Cole (PC) Staff Governor - Nursing/LD Simon Cottingham (SC) Stakeholder Governor - Children’s Society Sonia Davies (SD) Public Governor - Sandwell Alan Dean (AD) Public Governor - Wolverhampton

Jasbinder Dehar (JD) Public Governor - Wolverhampton Sabrina French (SF) Public Governor - Sandwell David Gratwick (DG) Public Governor - Sandwell Rizwan Jalil (RJ) Sandwell - Public Governor Oliveth Lawrence (OL) Staff Governor - Nursing/Psychiatry Mark Wood (MW) Public Governor - Birmingham & Wider West Midlands Bambul Miah (PS) Public Governor - Walsall

Mel Passmore (MP) Public Governor (Lead) - Wolverhampton Bob Piper (BP) Stakeholder Governor - Sandwell Council Paul Riley (PR) Public Governor - Dudley Parmjit Sahota (PS) Public Governor - Dudley Sandra Samuels (SS) Stakeholder Governor - Wolverhampton City Council Doreen Till (DT) Public Governor - Walsall

Councillor David Vickers (DV) Stakeholder Governor - Dudley MBC In Attendance Peter Axon (PA) Chief Finance Officer Joyce Fletcher (JF) Executive Director of Nursing, AHP’s, Psychology and

Governance (Interim) Natalie Grainger (NG) Governance Support Manager

Andy Green (AG) Company Secretary Judy Griffiths (JG) Head of Operational HR Joy Jeffrey (JJ) Non Executive Director Fayaz Malik (FM) Non-Executive Director Michelle Rogan (MR) Corporate Governance Director Tracy Taylor (TT) Chief Executive Lesley Writtle (LW) Executive Director of Operations

Apologies: Shindo Barquer (SB) Public Governor - Dudley David Hellyar (DH) Public Governor - Wolverhampton Cllr. Ian Robertson (IR) Stakeholder Governor - Walsall Kathy McAteer (KM) Non-Executive Director

Peter Sinclair (PS) Public Governor - Walsall

Encl. 1.3

Ref Item Action

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Suvanthi Subbarayan (SS) Staff Governor - Medical Lloyd Walters (LW) Public Governor - Sandwell Owen Young (OY) Public Governor - Dudley

Ref: Item Action 1 OPENING MATTERS

Ms Newton welcomed new governors, Mr Bambul Miah, public governor for Walsall, Mr Parmjit Sahota public governor for Dudley, and former Non Executive Director of the Trust. She also welcomed Mr Fayaz Malik, Non Executive Director, who was in attendance to present item 4.5. Ms Newton introduced Mr Peter Axon, Interim Chief Finance Officer and Ms Michelle Rogan, Interim Corporate Governance Director. Ms Newton asked for thanks and appreciation to be recorded to governors who have recently resigned and referred to the report later on the agenda. Governors who attended the annual planning event on 1st March 2017 were thanked and it was reported that feedback was positive.

1.1 Declaration of Interest Mr Malik declared an interest in item 3.1.

1.2 Apologies for Absence As listed above.

1.3 Minutes of the previous meeting The minutes of the previous meeting were agreed as a true and accurate record.

1.4 Matters Arising not on the agenda Ms Newton confirmed that feedback on the External Review would be reported under private session.

2 MATTERS ARISING

2.1 Action Log The action log was discussed and updated.

3 MANDATORY DUTIES

3.1 Re-appointment of Non-Executive Directors Mr Malik left the meeting as he had declared a conflict of interest in this item. Ms Newton reported that the current term of office for Ms Kathy McAteer and Mr Fayaz Malik (existing Non-Executive Directors) end on 31st July 2017 and 31st August 2017 respectively.

Ref Item Action

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She made the recommendation that both are reappointed for a one year term, taking into account the possibility that the Trust will cease to exist at the end of September 2017. Ms Newton confirmed that this would provide continuity throughout the transaction process along with flexibility if the transaction were not to take place. Ms Newton confirmed that the Governor Led Nominations Committee had agreed with the recommendations and proposed that they are approved by the Assembly of Governors. IT WAS RESOLVED:

(i) To reappoint both Ms McAteer and Mr Malik as Non-Executive Directors for a further one year term of office commencing 1st August 2017 and 1st September 2017 respectively.

3.2 Appointment of Associate Non Executive Director

Mr Green presented the report and requested delegated authority to the governor led interview panel in order to expedite the matter. Ms Newton reminded the assembly that they only had a statutory duty for the recruitment of Non-Executive Directors and not Associates. IT WAS RESOLVED:

(i) To delegate authority for the appointment of an Associate Non Executive Director to the Governor Led Interview Panel.

4 OTHER

4.1 Transforming Care Together - Governor Engagement and Approval (i) TCT Presentation

Ms Taylor was invited to provide a presentation on the progress of integration work for Transforming Care Together. Mr Cottingham asked how the voices of service users and carers were being incorporated into the transformation of services and raised that he didn't see this included within the integration plan. Ms Taylor confirmed that a clear directive had been given to clinicians leading the work regarding expectations for them to work with patients and carer’s when transforming services. Ms Taylor confirmed that the Integration Plan was only a high level structure and therefore does not provide this level of detail. Mr Cottingham suggested that it would be useful to have another workstream for community engagement. Ms Taylor felt that this was a

Ref Item Action

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valid point and confirmed that she would look at how this could fit in. Mr Dean agreed with Mr Cottingham and added that there was nothing within the integration plan that related to reporting to governors. Ms Taylor confirmed that this would be reported later on the agenda. Mr Cottingham raised the importance of the IT Infrastructure workstream also looking at the community context i.e. social media and hoped that service users and partners would be included. Mr Cash asked whether service users had been part of the enabling workshop. Ms Taylor confirmed that a staff workshop had taken place earlier in the day and that staff who had attended were tasked with spreading more widely. Mr Cash highlighted the importance of ensuring that service users and members understand the information that is being provided. Ms Taylor reported that the partnership were in a unique position and had the opportunity to pave the way nationally and confirmed that a structured and engaging approach was being taken. Ms Bolland raised that mergers and acquisitions had costs attached and asked how much this was expected to be and how long it would take to re-coup, particularly in light of the long waiting lists and clinicians’ time being taken away from their day job. Ms Taylor confirmed that it was clear that business as usual was the priority, and that it was anticipated that as a result of TCT, waiting times should be reduced. Mr Axon reported that initial calculations of costs for the acquisition were in the region of £0.5m, which was a disappointing use of tax payer’s money. He confirmed however that discussions had taken place with NHSI in an effort to minimize expense, to advise key areas where third party approval was required to be commissioned at a cost of approximately £150k. He confirmed that it was anticipated that everything else would be done in house. Mr Dean asked how the Board of the new organisation proposed to transform itself, as governors were expected to sign off prior to acquisition so it was important to understand. Ms Taylor confirmed that joint Board meetings were planned and that Board composition and management structure were currently being reviewed. The governors were reminded that the acquiring organization would form the core of the board although the partnership was built on the principles of best people and continuity which would be applied. Mr Cottingham asked whether there was a link between Non-Executive

Ref Item Action

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Directors and the workstreams. Ms Taylor confirmed that an NED from each organisation were on the integration board. She agreed to send governor’s members of the Integration Board and suggested Mr Fry attend the May meeting of the Assembly to provide feedback from the Integration Board. Mr Riley raised that the outcome of the workstreams were not clear. Ms Taylor confirmed that the workstreams have to agree and develop outcomes and that clinical workstreams had been tasked with ensuring improved outcomes. The outcomes will then form part if the measures within the benefits realisation. It was agreed that any further questions be emailed to Ms Grainger, Ms Newton or Mr Green. IT WAS RESOLVED:

(i) Ms Taylor to provide governors with members of the Integration Board

(ii) Mr Fry to be invited to the May governor meeting to provide an update on the Integration Board.

(iii) Service user involvement to be reviewed (ii) Transforming Care Together – Governor Engagement and Approval Mr Green presented the report which provided timescales for the approval process and outlined the governor’s role within this process and how the Board will engage effectively with governors. He highlighted that key dates had been highlighted within the report. Mr Green confirmed that a process would need to be put in place for all governors to vote on the acquisition and the outcome of this would be reported at a governor meeting. In response to a question from Mr Piper, Mr Green confirmed that the options for voting would be a simple ‘yes’ or ‘no’ however as part of the wider engagement process there would be opportunities for governors to ask questions prior to voting. Ms Newton drew attention to the paragraph included on page 26: ‘provided appropriate assurance is obtained, governors should not unreasonably withheld their consent for the proposal to go ahead’. In response to a question from Mr Gratwick, Mr Green confirmed that if the acquisition was approved, and the transaction date was 1st October 2017, the BCP governing body would dissolve on 30th September

Ref Item Action

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2017 and the governing body of BCHC would continue. He confirmed that there was a workstream as part of the Integration Plan which will ensure that the governing body covers all areas served and NHSI will want to ensure the constitution s representative of areas. Ms Rogan confirmed that she was keen for governors to be involved with informing the constitution of the new organisation and governors at BCP would have the opportunity to be elected for some of these posts. Mr Passmore raised that a number of governors were due for re-election during August and September 2017. Mr Green confirmed that this was addressed later on the agenda. Mr Cottingham asked how realistic it was for the workstream to have been reassured that service users have been consulted given the timescales. Ms Taylor confirmed that a great deal of work had already been done over the last 12 months and reminded the Assembly that there was not a requirement to formally consult. Ms Rogan confirmed that BCHC had a governor workshop planned for March 29th 2017 which will be run by Capsticks and will include Communications/Organisational Development leads to provide an update on the engagement plan. Governors were invited to attend, noting however the short notice. Ms Rogan confirmed that if governors were interested in attending but were unable to due to short notice that an alternative date could be put on. Mr Sahota felt that governors should have been invited at an earlier stage. Mr Dean raised that it would be useful for dates to be provided within the high level timeline to ensure maximum attendance of governors. Mr Cottingham suggested that the Chair be tasked with making robust representations to the other partner boards to consider BCP governors to ensure they are fully involved. Ms Newton provided assurance that she had had, and would continue to have, discussions with the Chair at BCHC. She agreed to raise the points at the sponsor group and ensure that dates would be circulated as soon as possible. IT WAS RESOLVED:

(i) Ms Newton to discuss with partner Chairs to ensure BCP governors are fully involved

(ii) Key dates to be worked up as soon as possible.

Ref Item Action

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4.2 Operational Performance of the Trust to Month 10

Mr Axon presented the report and confirmed that finances were ahead of plan at month end due to an asset revaluation. He reported however that due to the asset revaluation, the forecast outturn position deteriorates relative to plan to the end of the year. Mr Axon reported that it was expected to hit plan at year end. It was reported that non-recurrent CIP’s would provide an underlying issue for 2017/18 as approximately half of the CIP schemes were non recurrent, and the reason the Board signed off a larger deficit for 2017/18. Mr Axon reported that the income position was an adverse variance against income, requiring a recovery plan . The Capital programme was reported as being on track and the cash position was better than planned. Mr Axon reported that the cash position was tolerable assuming the TCT transition meets current timelines. Otherwise distressed funding would have to be accessed at some point during 2017/18. In response to a question from Ms Bolland, Mr Axon confirmed that any debts would be taken on by the acquiring organisation and the balance sheets would be consolidated at the transaction date. IT WAS RESOLVED:

(i) To note the report

4.3 Board Assurance Framework (including High Level Risks) Mr Green presented the Board Assurance Framework for information and reported that the Board manages these high level risks. He reported that Internal Audit were required to audit the Board Assurance Framework and had provided substantial assurance. IT WAS RESOLVED:

(i) To note the report.

4.4 Composition of the Assembly of Governors Mr Green reported that there are currently three vacant public governor seats which will rise by a further three in August and a potential further one subject to the Assembly’s decision. He confirmed that there were four staff governor vacancies and in an attempt to attract staff governors proposed changes have been made to the Constitution.

Ref Item Action

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In response to a question from Mr Cash, Mr Green confirmed that there was a Staff Governor Recognition Framework in place which recognized that the role was voluntary and could impact on duties. Mr Passmore asked whether the three governors whose term was coming to an end could have an extension in light of the position with TCT. Mr Green confirmed that he had checked with NHSI and they had advised that this was not possible. Mr Rogan reported that a representative from NHSI was present at the Integration Board and had indicated that a pragmatic approach should be taken in such circumstances. She highlighted the risks of losing long standing governors and potentially new governors being elected for a short period of time, who would be expected to vote on extremely important matters. Mr Green agreed that he would contact NHSI again to clarify their position. In response to a question from Mr Cash, Ms Newton confirmed that as part of the strategic review process which had been undertaken during 2015, NHSI had advised that BCPFT would not be in a position to be the acquirers in any transaction due to our financial position and as BCHC were a Foundation Trust they were best placed to be the acquirers. Mr Green raised that if NHSI agreed to extend the terms of office for the three affected governors, there remained seven vacancies and consideration should be given to how this can be addressed. IT WAS RESOLVED:

(i) Mr Green agreed to contact NHSI again to clarify their position with regards to the extension to terms of office for governors

(ii) To remove Mr Young from his position as Public Governor for Dudley

(iii) To approve changes to the Constitution in relation to staff governors

(iv) To develop a pragmatic solution to the vacancies and re-appointment’s

4.5 Presentation by Non-Executive Director

Mr Malik presented on his role as a Non Executive Director and Chair of Charitable Funds Committee. Mr Gratwick asked for assurance that service managers know how to access the funds.

Ref Item Action

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Ms Writtle confirmed that there was a process in place however further work was required to ensure the process was made simpler and easier to access. In response to a question from Mr Passmore, Mr Axon confirmed that charitable funds would transfer to the new organization. Ms Newton confirmed that if funds had been specified they would have to be spent in those areas. In response to a question from Mr Cash, Ms Newton drew attention to the list of investments of Charitable Funds within the presentation. IT WAS RESOLVED: (i) to receive the presentation

4.6 National Reports of unexpected deaths in the Health Service Ms Fletcher presented the report which provided assurance that the Trust have reviewed the recommendations and that the Medical Director and Director of Nursing had been involved in local and National reviews. She reported that common issues had been identified, particularly around engaging with families early and involving them in any investigations. Ms Jeffrey confirmed that she had attended an event that day and the key message was again engagement with families. IT WAS RESOLVED:

(i) To note the report

4.7 Register of Interests Mr Green presented the Governor Register of Interests for approval. Mr Cottingham raised that he had an interest which was declared at the previous meeting and should be included. IT WAS RESOLVED:

(i) To include interest for Mr Cottingham (ii) To approve subject to the above amendment

The Chair thanked all for attending the Committee and closed the meeting.

Action Ref Action Lead Comments Required

Completion

Date

Date

Completed

Status

170516/2.2 To receive detail of the work on Equality and

Inclusion Task Group at a future meeting

J Fletcher Report at January

Board of Directors

to link in with NED

presentation in May

May-17 Open

170117/4.3 send the governors the process for sharing lessons

learnt

J Fletcher To be distributed

outside of the

meeting

May-17

Update

Open

170117/4.7 Ms Writtle to meet governors outside the meeting to

provide a briefing on Dudley MCP.

L Writtle May-17

Update Open

210317/4.1(i) Governors to be provided with details of the

members of the Integration Board

T Taylor May-17

Update Open

210317/4.1(i) Mr Fry to be invited to the May meeting to provide

an update on the Integration Board

J Newton

May-17Open

210317/4.1(ii) Ms Newton to discuss with Partner Chairs to ensure

BCP governors are fully involved

J Newton May-17

Update Open

210317/4.1(ii) Key dates for governors to be worked up as soon as

possible

J Newton

A Green

May-17

Update Open

210317/4.4 Mr Green agreed to contact NHSI again to clarify

their position with regards to the extension to terms

of office for governors

A Green

May-17

Update

Open

210317/4.4 To develop a pragmatic solution to the vacancies

and re-appointment’s

A Green May-17

Update Open

Items scheduled as per cycle of business that have been deferred

Item By whom Due

Deferred to

Annual Operational Plan Mar-17 TBC

Items requested for future agenda's Requested byComments When

Staff Survey 2016/17 P Cole required to be

reported to

Board in Mar-17

prior to AOG

May-17

Smoke Free Premises P Cole TBC

Assembly of Governors Action Log

Encl. 2.1

Report to: Assembly of Governors Date: 16th May 2017 Subject: The role of the Equality and Inclusion Board Author & Emma Louis, Head of Diversity and Spirituality Designation: Purpose of report: Relationship of matter to duties of the Assembly:

Statutory duties: To hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors.

The appointment or dismissal of the Chair and other Non-Executive Directors. The determination of the remuneration and terms and conditions of the Chairman and Non-Executive Directors.

The approval of the appointment of the Chief Executive Officer. The appointment or removal of the Auditor to the Trust. To receive and consider the Annual Report and Accounts. To review the Annual Plan, as presented by the Board of Directors To represent the interests of the members of the trust as a whole and the interests of the public.

To approve the provision ( and continuation) of activities other than the provision of goods and services for the national health service in England.

To approve proposed increases of 5% or more in annual income received from activities other than the provision of goods and services for the national health service in England.

To approve amendments to the constitution, To approve an application for a merger with, or acquisition of another NHS Trust or NHS Foundation Trust, or the separation or dissolution of the Trust

To approve for the Trust to enter into a “significant transaction”, (as described in the Constitution) Other duties:

To approve the appointment of the Senior Independent Director To appoint the Deputy Chair of the Trust To appoint the Lead Governor To remove a governor from office To call elections for governor seats To invite next highest polling candidate to take a governor seat To approve the local Quality Account indicator for review by External Audit To approve the disqualification of members of the Trust To be consulted on the appointment or removal of the Trust Secretary None x

Regulatory and/or compliance matters:

NHSI:

To approve To receive For information x

Encl. 2.2

Care Quality Commission:

Other:

x None:

Indicate where matter has been subject to review by Non-Executive Directors

Board of Directors Audit Committee

Finance &Investment Committee

M H Legislation Scrutiny Committee

Quality & Safety Committee Other:

None x

Recommendation(s):

To receive the report for information.

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Equality & Inclusion Board Annual Report April 2017

This report provides updates and an overview relating to the following areas of work of the

Equality & Inclusion Board over the last year:

Equality & Inclusion Board (EIB) and Governance

Play Fair Equality Strategy & Equality Objectives

Public Sector Equality Duty (PSED) & Equality impact Assessments (EqIA)

Workforce Race Equality Standard (WRES)

Equality Delivery System 2 (EDS2)

Accessible Information Standard (AIS)

Workforce Disability Equality Standard (WDES)

MERIT Vanguard Equality & Diversity Workstream

NHS Employers Diversity & Inclusion Partners

Staff Networks

Equality & Inclusion Training

Care Quality Commission (CQC) Report & Equality

Interpreting & Translation Service

Migrant Health Resource

Spiritual Care Team

1. Equality & Inclusion Board

The Trust’s Equality & Inclusion Board (EIB) meets bi-monthly. This group has supported the

trust to improve the visibility of the importance of the equality and inclusion agenda, raising

the profile across all areas of work, and will continue to drive this forward. This Board has

been chaired by the Executive Director for Nursing, Governance, AHPs & OD and has

recently refreshed its membership to include representatives from AHP, Psychological

Boards and the Strategy & Transformation Director.

There is a clear annual cycle of business for the EIB in terms of compliance deadlines,

internal and external reports and equality & inclusion related national and local events. A

recent addition to the Agenda of EIB is an opportunity for the Clinical Groups to report back

on things that are going well and things that need further progress in relation to equality

and inclusion. This will continue and be linked to clearer reporting on equality and inclusion

in the reports prepared for QSSG. This enables the EIB to also hear good news stories, learn

from them, and cascade good practise and areas for improvement around the Trust.

As we move towards becoming one organisation with Dudley and Walsall Mental Health

Partnership Trust and Birmingham Community Healthcare NHS Foundation Trust, through

the Transforming Care Together Partnership, all the different elements of the Equality and

Inclusion agenda will need reviewing including the role of a Trust wide EIB. The 3 equality

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leads from the different organisations have already done some benchmarking to see where

we are each up to in our respective organisations and to look at how we integrate this

particular area of healthcare.

2. Play Fair Equality Strategy and Revised Equality Objectives

The ‘Play Fair’ accessible version continues as our main Trust statement around equality and

inclusion. The more detailed version has been revised in line with the latest national

developments in equality and inclusion and to include up to date information relating to the

Trust. New revised Trust equality objectives are just being finalised which will be included in

this longer more detailed version of Play Fair. These have been created using the following:

The WRES (Workforce Race Equality Standard), WDES (Workforce Disability Equality

Standard), PSED (Public Sector Equality Duty of the Equality Act 2010) and the AIS

(Accessible Information Standard), all of which are national mandatory equality

drivers.

The Trust’s current Strategic Objectives and Visions and Values

The previous objectives of Play Fair which related to: embedding governance

structures around equality, make better use of equality information, support an

inclusive culture for staff and build stronger relationships with diverse local

communities.

The SOMS (Sexual Orientation Monitoring Standard) which comes in from April

The Evidence gathered from our EDS2 exercise last summer relating to our equality

performance in our services and workforce.

The current equality objectives from the Trusts which we will be integrating with

from October (TCT).

These refreshed objectives are for 12 months, after which there will need to be new revised

objectives across the whole of TCT. Once the Objectives are agreed by EIB (currently in

progress) an action plan can be created with key priorities around each objective. There are

5 proposed objectives, based around the WRES, the WDES, the SOMS, and community

engagement.

3. Public Sector Equality Duty (PSED) and Equality Impact Assessments

To provide services that are relevant and accessible to the needs of the population we

serve, our workforce needs to reflect the diversity of the Black Country and we also need to

build a clearer picture of the people using our services, those who might potentially need

our services and those involved in helping us to develop them. To enable us to do this we

need to gather as much ‘equality information’ as we can. Equality information is collected

by the 9 personal characteristics protected by the Equality Act - age, disability, gender-

reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and

belief, sex (gender) and sexual orientation.

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As well as using this information to help us develop our services we are also required to

share and publish all this information, updated annually, as part of our equality duty as a

public sector body. The annual refresh of our Trust’s equality information happened in

January, and was published on our website’s Equality Information Hub. We are aware that

there are areas for improvement where we do not have as much information or the level of

detail as we would like. Improving the quality of our equality information continues to be

one of our key equality objectives.

Information includes:

Demographics of The Black Country by Borough

Data on who is accessing our services by protected characteristic and Borough and

service

Mental Health Act data

Interpreting & Translation Data

Workforce data

Learning & Development Data

Membership Data

Incidents and Complaints Data

Also, as mentioned above, we now have revised equality objectives in place for 2017-2018.

Publishing our equality information and having equality objectives are part of our specific

duties for the Equality Act 2010 along with having an equality strategy – Play Fair - and

demonstrating that we are carrying out Equality Analysis.

We continue to use an Equality Impact Assessment process within the Trust to help with this

equality analysis. Our Equality Impact Assessment (EqIA) form and process has recently

been revised to enable there to be a register of EqIAs held on Datix (a quality monitoring

system) and for resulting actions to be tracked and monitored through a more robust

process than currently exists. The form now automatically goes to the Governance

Assurance Unit as well as to the Equality & Diversity Team to ensure that the process isn’t

dependent on one person. The authors of EqIAs, and related action plans, will get

notifications relating to required actions mitigating possible potential negative impacts.

Reports on progress against these actions will come to EIB.

4. Workforce Race Equality Standard (WRES)

We published our WRES information for 2016 in line with national timescales and our WRES

return and initial action plan can be found on both the website and our Intranet.

There was a specific WRES Task & Finish Group (reporting back to EIB) looking at how we

will implement and monitor the action plan. Members of the Black and Minority Ethnic

(BME) Staff Network have also been involved in inputting into the action plan. The Action

Plan has now been placed on the Quality Improvement Plan (QIP) to enable robust and

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direct monitoring and reporting back to EIB. The Summary of the WRES returns from 2015

and 2016, and progress made, can be viewed at Appendix 1. The owner of the WRES action

plan is the Associate Director of Human Resources.

We will be required to complete our 3rd year of the WRES in July this year - 2017. In 2018

the WDES (Workforce Disability Equality Standard) will be launched to enable a similar

process to be focussed around disability in the workforce.

In January 2017, NHS England visited some executives and a small BME focus group, at the

Trust, to find out more about how we have been able to close the gaps on the some of the

indicators while other Trusts haven’t done so well.

Parallel to this a researcher working for Roger Kline (author of Snowy White Peaks and

Appointment by Discrimination reports) met with the Head of Diversity & Spirituality to look

specifically at the positive work the Trust has done around Indicator 2 which focuses on

recruitment. This research will be written up, and the good practise being carried out at this

Trust will be shared at national events reflecting on the progress of the WRES.

An action on the WRES Action Plan was for the Trust to support staff to apply for the

Stepping Up Programme. The Stepping Up programme is a national leadership development

programme for Black, Asian and minority ethnic (BAME) colleagues who work within

healthcare. It aims to create greater levels of sustainable inclusion within the NHS by

addressing the social, organisational and psychological barriers restricting BAME colleagues

from progressing. The programme is designed to bridge the gap between where applicants

are and where they need to be, to progress into more senior roles. Successful applicants will

be empowered to drive forward the inclusion agenda and develop their skills and abilities in

order to grow and progress. The programme fits with the Academy’s wider body of powerful

positive action work to promote diversity and inclusion throughout the health service. The

ultimate aim is to develop more inclusive leaders at all levels of the NHS. This programme

will link into actions contained in the WRES Action Plan relating to Career Development and

Leadership.

Another initiative linked to the WRES Action plan is the role of Cultural Ambassadors. The

Cultural Ambassadors project in the West Midlands is designed to tackle disproportionate

rates of disciplinary action among BME staff, is to be rolled out nationally by the Royal

College of Nursing (RCN). Here in BCPFT we have committed to this project along with our

TCT partners. It is open to Band 7 staff from a BME background. Once trained the Cultural

Ambassadors (CA’s) will participate in disciplinary investigations of BME staff, and support

the Trust to assess whether there are improvements that can be made, and cascade their

learning throughout the organisation. The details of how this happen and implications for

the workforce are currently being worked out.

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5. NHS Equality Delivery System 2 (EDS2)

During August 2016, work on EDS2 moved forwards in a major way. EDS2 is a tool to help

Trusts meet their PSED. There are various stages to the process and one of them is gathering

evidence from services and departments across the Trust to help us then work with

stakeholders to grade our equality performance and work out where we are doing well and

where we need to improve. An audit tool was created and 20 services from across the Trust

(a good mix from different areas) responded. Information was compiled into a Trust-wide

summary which was shared with local stakeholders. This included the building of some

really positive links with Sandwell College Health students, working with the Carers Team

and also liaising with one of our Public Governors. Clinical Groups can look in detail at the

evidence gathered from their different services to look at how they use the information to

help meet their local objectives. The EDS2 summary will now be placed on our website and

submitted to NHS England. We have now used the evidence gathered to establish where our

work priorities need to be over the next 1 year and have created our new Equality

Objectives mentioned above.

6. Accessible Information Standard (AIS)

The NHS Accessible Information Standard, which came in last year, tells organisations how

they should ensure that disabled patients receive information in formats that they can

understand and that they receive appropriate support to help them to communicate.

The hope is that the Accessible Information Standard will begin to address the current

disparity in the care received by disabled people and ensure needs are recorded and met.

Adult social care and NHS providers legally needed to fully implement the accessible

information standard by 31 July 2016.

The 5 areas of the AIS are as follows:

Identify Need

Record Need

Flag Need

Share Need

Meet Need

Last year the BCPFT Accessible Information Standard Group met and made progress leading

up to the different stages of implementation in line with a detailed action plan. The 3

Clinical Divisions have all taken a slightly different approach to implementation. An update

will be brought to the May meeting of EIB to ensure that the standard is in place across the

Trust and that any issues can be raised and responded to in a timely manner.

7. Workforce Disability Equality Standard (WDES)

6

The Equality and Diversity Council (EDC) in July 2016 has recommended that a Workforce

Disability Equality Standard (WDES) be mandated from April 2018, with a preparatory year

from 2017-18.

The Equality Diversity Council considered the report published by Middlesex and

Bedfordshire Universities on the ‘Experience of Disabled Staff in the NHS‘, alongside findings

from research carried out by Disability Rights UK and NHS Employers ‘Different Choices,

Different Voices‘, which found that disabled people had poorer experiences of working in

the NHS in England than non-disabled colleagues.

Consultation on the proposed Workforce Disability Equality Standard has begun, alongside

an extensive programme of communications and engagement to raise the profile of this

initiative and to outline what support will be provided to organisations to deliver the change

with disabled staff.

As with the WRES, the WDES is about measuring progress on disability and looking at closing

the gap between the experience of disabled staff and those without a disability. There are

11 proposed metrics (two more than WRES), some of which again are linked to the Staff

Survey. They are currently at draft stage and will be finalised at some point in the Autumn of

this year 2017. A toolkit will be introduced to support bringing in the WDES.

One of the main issues currently being raised by those preparing for the WDES is that,

whereas most of the workforce will declare their ethnicity, a very low percentage of the

workforce declare whether they have a disability or not. Currently within BCPFT it stands at

1%. We know this is actually higher because in the staff survey, where anonymity is assured,

19% of those who responded said they had a long standing health problem or disability. The

low numbers of people in the workforce feeling they can say that they have a disability

means that gathering information for the WDES metrics will be very hard. We cannot

currently get a true picture. With this in mind one of our revised Trust Equality Objectives

focuses on creating change in this area.

Whilst we await the toolkit, and final version of the metrics, a BCPFT WDES Action Group is

evolving to begin to do some benchmarking around disability in the workforce here at

BCPFT, to look at other initiatives we are involved in around disability (including learning

disabilities and mental health) and to look at how we will prepare for the implementation of

the WDES. The first meeting of this group took place in February 2017 and included both

disabled and non-disabled members of staff. The second took place in April. Communication

has gone out Trust wide and to managers asking members of the workforce to come and

join the conversation around disability.

8. MERIT Vanguard Equality Work-stream

Emma Louis and Yassar Mohammed (the BCPFT Equality & Diversity Team) are both

involved in the Equality work-stream of the MERIT Vanguard (being led by Dudley & Walsall

7

MHPT). The current focus is on encouraging each of the work-streams to carry out an

equality analysis on their area of work to ensure that the work of the vanguard is

considering impacts on different equality groups. The Equality & Diversity Work-stream also

has a close relationship with the Recovery work-stream in relation to community

engagement and the need to promote an understanding of recovery in the community and

build on resources already there. The Equality & Diversity work-stream have hosted or

supported a number of events through the last year (some jointly with RCN) including a

successful and well attended MERIT wide Black History Month conference in October 2016,

an EDS2 regional roadshow in January and the HEE forward Thinking leadership Inclusion

Conference in March.

9. NHS Employers Partners Diversity & Inclusion Programme

As part of the MERIT Vanguard Equality Work-stream, and along with the other 3 Trusts in

the Vanguard, BCPFT were invited to be Diversity & Inclusion Partners by NHS Employers.

There are 5 meetings a year in London. The Head of Diversity & Spirituality has attended 4

of these meetings to represent the Trust and has been accompanied by either the NED who

attends the EIB, or our Associate Director of Organisational Development in whose portfolio

Diversity and Inclusion sits. Themes focussed on through the year have been disability –

including mental health - and the workforce, gender and the workforce, taking stock on all

the mandatory national drivers around equality and celebrating good practise. We have

been invited to be part of this national programme for a second year. It has been very useful

to implementing of the various national initiatives in BCPFT and has also raised the profile of

our Trust and the way we have engaged with this agenda. At the final meeting of this year’s

programme, everyone who has been part of it, including BCPFT, received a recognition

award celebrating their contributions towards this agenda.

10. Staff Networks

BCPFT has a BME Staff Network and a Lesbian, Gay, Bisexual, Transgender (LGBT) Staff

Network.

The Terms of Reference of the BME Network have been revised and discussions took place

to bring clarity to the role of the Network and its role including strengthening the way it

relates to the work around the WRES. The Network reports into the EIB with updates on its

activity. The BME Network have hosted some resilience training which was open to all Trust

staff, and are supporting the development of coaching and mentoring in the Trust. Other

themes have included interview skills and support from HR, supporting the applications for

the Stepping Up programme and more general sharing and support for members. The

network will lead on plans for this year’s Black History month celebrations.

The LGBT Staff Network is currently being reviewed. The Network hasn’t gathered for a

while now and has been functioning as a virtual group sharing information and resources.

8

The person who has been leading the LGBT Network and was the key contact for queries in

this area has now left the Trust, so there is a gap in terms of how that Network is supported.

The Equality & Diversity Officer is overseeing the development of both networks as they

move forward.

11. Training relating to Equality & Diversity

Equality & Diversity continues to be a key element of mandatory training for all our

workforce. How we offer our mandatory training has been reviewed as part of the regional

streamlining of mandatory training and also the internal review of mandatory training and

induction, so the basic equality and diversity awareness training has now gone on line

through OLM and is only required every 3 years. There is still an equality and diversity

element to our Trust Induction closely aligned to our work around Trust values, dignity and

respect. Equality and Diversity elements are also key elements of our Managing & Leading

for Excellence training programmes but these are currently on hold. The Equality & Diversity

Team, up until last year, continued to offer bespoke sessions with Staff Teams around

practical application of Play Fair and also training on working effectively with interpreters.

As part of TCT this whole area of how we best equip our staff to work in inclusive ways and

in line with national compliance will be reviewed and what elements might still be best

served by a more experiential face to face form of training.

12. CQC Equality & Inclusion Lines of Enquiry

There has been a national development in terms of how CQC explore lines of enquiry

around equality and diversity since our initial CQC visit in Autumn 2015. The Equality &

Diversity Team worked with the Governance Assurance Unit (GAU) team to feed the CQC

information on our compliance with all the national initiatives for the return visit in 2016.

There was a special communications feature highlighting developments and good practise in

Equality & Inclusion work, to ensure that staff across the Trust were aware of progress

made, current areas of work, and how it relates to them. The Equality & Diversity Team

along with Executive Director of Nursing, Associate Director of OD and Head of Employment

services met with the CQC to share good practise and update them on our progress since

last year. The interview was very positive with lots of opportunity to share how the team

felt things had improved and developed at the Trust in relation to Equality & Inclusion since

last November and what we still felt we now needed to focus on.

When the CQC full report was received in February 2017 it was clear to see that the CQC felt

we were compliant with the Equality Act 2010. Parts of the report refer directly to national

equality and inclusion compliance and also to particular instances where equality and

inclusion have been promoted through the quality of care offered and the responsiveness of

services. Elsewhere, equality and inclusion and dignity and respect could be seen as threads

9

running through positive comments on, for example, use of MH Act, use of restrictive

interventions, enabling groups to have a voice, the complaints process.

13. Interpreting and Translation Services

We continue to use Absolute Interpreting & Translation Services for our needs around face

to face and phone interpreting and written translation. This last year has seen a review of

the procurement process and also of the online booking process, to ensure that our needs

are met smoothly. The most frequently requested languages by a considerable margin are

Polish and Punjabi, followed by Urdu, Farsi, Kurdish and Romanian.

14. Migrant Health Project

Our new Intranet Resource for staff focussing on migrant health has been launched. This is

intended to support staff in understanding the asylum and refugee process as it relates to

health and the care and services we provide in our Trust. Staff are invited to start using this

and comment on how it can be improved and evolve.

15. Spiritual Care Team

The patient facing Spiritual Care Team (Trust chaplains), continues to sit alongside the

Trust’s Equality & Diversity function and is managed by the Head of Diversity & Spirituality

(who also works as one of the team). The Team of 8 chaplains (around 3.2 WTE) work Trust-

wide across the different clinical groups and their activity is reported into the Group Quality

and Safety Reports on a quarterly basis. Each Team member is from a different faith or

belief group including Hindu, Muslim male and female, Sikh and the Christian traditions of

Church of England, Methodist, Old Catholic and Pentecostal. Three of the Team are female

and 5 are from a BME backgrounds. The Team is currently supported by the work of 3

volunteers who have been trained for the role by attending the Birmingham and Black

Country Healthcare Chaplaincy Volunteers Training programme. The volunteers are based at

Edward Street Hospital where they visit on the wards and as part of a Garden Project at a

Church in Wolverhampton where clients from our Community Teams are involved.

The services of the Spiritual Care Team are for anyone who is receiving support from one of

the teams or services in the Trust, including carers. The Spiritual Care Team also offers

informal support to staff and some members of the Team facilitate regular Mindfulness

Meditation Sessions to help reduce stress.

The spiritual part of someone’s life can be an aid towards recovery and a comfort and

strength in times of stress and anxiety. Ensuring that people can draw on this spirituality is

an essential part of helping someone towards better well-being. We know not all people

express their spirituality through a particular faith or religion. With this in mind, the Team

makes sure their support is as much for those who don’t follow a particular faith or spiritual

tradition as it is for those who do.

10

The team supports people of various faiths and spiritual traditions through 1-to-1 sessions.

These can involve someone reflecting on their life, beliefs, and values, and could touch on

psychological, social, religious or spiritual themes. We also run group sessions on various

sites, often with other healthcare professionals, where people can explore their spirituality

or express their faith and beliefs, including a recent initiative as part of the Recovery

College.

Across the Trust an average of 40% of people we see identify as Christian, 20% as Sikh, 8%

Muslim and around 5% from smaller faith groups. The rest of our contact is with people who

don’t identify with any particular faith tradition but who wish to explore spiritual issues or

receive general support from the Team.

On average, the Team might have around 400 (1 to 1) contacts with patients each quarter.

In addition to this would be our group work, including the very popular Spirit of Song Group,

which uses music and singing to explore meaning and hope in life, and the Faith & Belief

Group at the Gerry Simon Clinic. The Team also highlights monthly key cultural and religious

festivals via the e-bulletin, so that staff are aware of days that are important to both their

colleagues and patients in their care, and is involved with the hosting of various cultural and

religious Festival events around the Trust.

The Spiritual Care Team is currently evaluating the service they offer and working with the

Patient Engagement & involvement Lead to gain specific patient feedback their work to help

take stock of the service offered and plan for development as part of the Transforming Care

Together integration plans. Part of the review has been completing a small data collection

project focussing on the extent to which spiritual needs are recorded in patient notes and

also doing two surveys around the group work and a pilot of weekend working.

Across the 3 TCT Trusts BCPFT has the only established, substantive, multi-faith Spiritual

Care team so the coming together of the 3 organisations offers an opportunity for service

improvement and creative development of Spiritual Care.

Report to: Assembly of Governors Date: 16th May 2017 Subject: Governor Gauge – 4th survey Author & Andy Green, Company Secretary Designation: Purpose of report: Relationship of matter to duties of the Assembly:

Statutory duties: To hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors.

The appointment or dismissal of the Chair and other Non-Executive Directors. The determination of the remuneration and terms and conditions of the Chairman and Non-Executive Directors.

The approval of the appointment of the Chief Executive Officer. The appointment or removal of the Auditor to the Trust. To receive and consider the Annual Report and Accounts. To review the Annual Plan, as presented by the Board of Directors To represent the interests of the members of the trust as a whole and the interests of the public.

To approve the provision ( and continuation) of activities other than the provision of goods and services for the national health service in England.

To approve proposed increases of 5% or more in annual income received from activities other than the provision of goods and services for the national health service in England.

To approve amendments to the constitution, To approve an application for a merger with, or acquisition of another NHS Trust or NHS Foundation Trust, or the separation or dissolution of the Trust

To approve for the Trust to enter into a “significant transaction”, (as described in the Constitution) Other duties:

To approve the appointment of the Senior Independent Director To appoint the Deputy Chair of the Trust To appoint the Lead Governor To remove a governor from office To call elections for governor seats To invite next highest polling candidate to take a governor seat To approve the local Quality Account indicator for review by External Audit To approve the disqualification of members of the Trust To be consulted on the appointment or removal of the Trust Secretary All duties indirectly X

To approve To receive X For information

Encl. 3.3

Regulatory and/or compliance matters:

Monitor:

Care Quality Commission:

X Other: Constitution of the Trust

None

Indicate where matter has been subject to review by Non-Executive Directors

Board of Directors Audit Committee

Finance &Investment Committee

M H Legislation Scrutiny Committee

Quality & Safety Committee Other:

None X

Recommendation(s):

To

Summary of main points in report

Governor Gauge is the survey tool used by the governors to help assess their skills and knowledge requirements in relation to their duties. The fourth survey was undertaken between January and February 2017. There was an overall response rate 42%, which was lower than in the previous year Generally, respondents indicated higher levels of confidence in their knowledge and skills to undertake their duties across all domains since the survey commenced in 2014. No further action is planned to review the Governor Gauge given the status of the Transforming Care Together Partnership and likely dissolution of the Trust in the autumn of 2017.

Introduction: Governor Gauge is the survey tool used by the governors to help assess their skills and knowledge requirements in relation to their duties. Individual responses are maintained in complete confidence and not shared with the Trust. Membership Engagement Services administer the survey and sends the Trust a report with an analysis of the aggregated survey results (Individual responses are maintained in complete confidence and not shared with the Trust). These reports are shared with governors and help inform the determination of areas that the Trust may need to support governors in acquiring and/or developing the relevant skills and knowledge. Governor Gauge is an online survey, split into five core domains relevant to the skills and knowledge requirements relating to the duties of the governors. The fourth survey ran between January and February 2017, and the key highlights from the initial analysis of this survey, as extracted from the report are discussed below.

Response rate 10 governors, (8 public governors, 1 staff and 1 stakeholder) completed the survey representing 42% response rate overall. This is disappointingly low and may have been affected by the churn in the membership of the Assembly at that time. Comments received since the survey suggest that some governors may have considered the survey to be of minimal benefit to themselves. General overview Overall, the sections in which responding governors had the highest levels of

confidence were; ‘Communicating between the Trust and general public’ and

‘Making Decisions about Key Roles within the Trust’ (83% of responses within both

of these sections being confident or very confident)

The section in which the governors continue to have the lowest levels of confidence

was ‘Holding the Non-Executive Directors to account’, with only 57% of the

responses within this section being confident or very confident.

However in general, governor’s confidence has grown in each of the survey sections

over the duration of the governor gauge programme, with the majority of sections

showing an increase in governor confidence for each of the 4 governor survey

periods.

Highlights from each domain

- Communicating between the Trust and general public

Overall, confidence levels of responding governors increased for this section,

with 83% of responses being confident or very confident compared to 71% in

February 2016.

It is also worth noting that the scenarios in this section that referred to

engaging with members and the public in particular (such as speaking to the

public about positive experiences or concerns about services), also showed a

large increase in confidence.

- Making decisions about keys roles within the trust

Overall, responding governors had a relatively high level of confidence for the

scenarios in this section with 76% of responses being confident or very

confident. This was a higher proportion than in February 2016 (71%)

- Holding the Non-Executive Directors to account

Overall, confidence levels of responding governors reduced slightly for this

section, with 57% of responses being confident or very confident compared to

63% in February 2016.

- Shaping the future of the organisation

There was a large increase in overall confidence for this section, with 80% of

responses being confident or very confident compared to 60% in February

2016.

- Trust Awareness

Overall, governors confidence in terms of trust awareness, governors

confidence increased, with 81% of responses being confident or very

confident compared to 68% in February 2016.

When looking at trust regulation, trust services and trust size and shape

governors reported high levels of confidence; all governors indicated that

they felt confident or very confident they knew, or knew where to find out,

about the key people/roles within the Trust. The levels of confidence for these

particular scenarios had increase from the February 2016 survey period.

The levels of confidence among responding governors were fairly consistent

around the Trust’s strategy, with 89% responding as confident or very

confident for the scenarios within this section.

Thinking about the Trust’s financial position, responding governors were most

confident they would know, or know where to find out, what were the biggest

financial risks the trust faces (67% being confident or very confident).This was

an increase from the February 2016 period (48% being confident or very

confident).

Conclusion It is slightly disappointing that this year’s survey had such a low response rate, but nonetheless encouraging that over the duration of its use, since 2014, the confidence of our governors in their knowledge about their roles has shown a continual increase. Moving forward, attention would need to be paid to ensuring - that the content of the survey is refreshed and relevant; and - that it can continues to serve its original purpose, and as necessary be adapted to meet new requirements. It would therefore be appropriate to establish a forum for governors, to be attended and supported by MES to undertake this review; however, it is not proposed to commence any work in this respect, given the current intention for the Trust’s services to be acquired and consequent dissolution of the Trust in the autumn of 2017. Consideration as to the future use of the Governor Gauge tool will be referred to in the integration work streams of the Transforming Care Together Partnership programme.

END

Performance UpdateFor Assembly of Governors

Presented by: Peter Axon – Chief Finance Officer

May 2017

Encl. 3.4

Performance Update – Month 12

YTD Actual

£'000

YTD Budget

£'000

YTD

Variance

£'000

Income 101,400 101,261 139

Employee Expense (81,771) (80,436) (1,335)

Non-Pay Expense (16,503) (17,823) 1,320

EBITDA 3,126 3,002 124

Depreciation and Amortisation (1,818) (2,046) 228

Surplus / (Deficit) from Operations 1,308 956 352

PDC (1,333) (1,585) 252

Other Non Operating Income & Expense (525) (500) (25)

Surplus / (Deficit) before asset revaluations (550) (1,129) 579

Net movement on asset revaluations (10,625) 0 (10,625)

Surplus / (Deficit) after asset revaluations (11,175) (1,129) (10,046)

Cash Balance:

£4.2m at 31st March 2017

Capital:

Spend to the end of March 2017 is £1,6131k.

£488k lower than the plan largely due to delays against phasing.

Debtor Position:

Balance at 31st March 2017 is £1,878k.

Performance Update

Cost Improvement Plans

Full year CIPs of £6,400k have been delivered against the original plan of

£6,395k. Non-recurrent savings total £3,467k. Recurrent savings total £2,933k.

The recurrent savings total includes the impact of the asset revaluation exercise.

Performance Update

YTD YTD YTD

Plan Actual Variance

Recurrent / Non Recurrent (£000) (£000) (£000)

Recurrent 2,532 2,230 -303

Non-Recurrent 3,862 3,467 -396

sub - total 6,395 5,696 -698

Recurrent - Revaluation 0 704 704

Total 6,395 6,400 5

Staff Survey 2016

Presentation to Assembly of Governors

Tuesday 16th May 2017

Encl. 3.5

Background• The NHS National Staff Survey has been running since 2003

• The biggest ongoing hospital staff survey programme in the world

• Used by NHS England, and the CQC to assess Trust Performance

• Used alongside the NHS Staff “Friends and Family Test”

• Definite correlations between staff engagement, patient experience

and patient outcomes

• The staff survey offers us the opportunity to understand the views of

staff and their experiences and can help to improve staff experience

Key findings

• The Trust’s response rate for the 2016 staff survey was

40% (773 out of 1913 sample), an increase from 34% in

2015, and slightly lower than the national average

response rate of 44% for similar organisations (L&D and

Community Services).

• BCPFT carried out a full census of and used a mixed

mode of 80% electronic; 20% paper.

Response rates per division

The Respondents2015 2016 All

Women 79% 80% 82%

Men 21% 20% 18%

White 77% 74% 89%

Ethnic Minorities 23% 26% 11%

Over 50s 42% 36% 42%

16-40 32% 33% 30%

Long standing health problem/disability 25% 19% 20%

Biggest occupational groups

Mental health nurse 18% 17% 13%

Admin & Clerical 13% 16% 16%

Key FindingsThis year there are 32 key findings. The key findings are presented in the feedback reports

under the following nine themes:

Appraisals & Support for development

Equality and diversity

Errors and incidents

Health and wellbeing

Job satisfaction

Managers

Patient care and experience

Violence, harassment and bullying

Working patterns

As in previous years, there are two types of Key Finding:

percentage scores and scale scores.

How scores are calculated – percentage scores

These are calculated as the percentage of respondents who gave a specific answer to a

question, for example KF11 ‘percentage of staff appraised in the last 12 months’

represents the percentage of people in each organisation who responded to the question

“in the last 12 months. Can’t remember responses are excluded from the calculation.

These response are then summarised for the entire organisation. For example:-

KF11 percentage of staff appraised in last 12 months

Trust score 2016 - 96%,

Trust score 2015 - 97%

National Average for combined MH/LD and community Trusts 92%.

The Trust remains above average

How scores are calculated - scale scores

Scale scores are worked out by assigning numbers to a serious of responses, and calculating the

average score. For example, Key Finding 4 “staff motivation at work was calculated in the

following way: Staff were asked to what extent to which they agreed

with three statements:

• I look forward to going to work

• I am enthusiastic about my job

• Time passes quickly when I am working.

• Trust Score 2016 – 3.92 National Average 2016 for combined MH/LD and community Trusts 9.94

• Trust score 2015 - 3.84

Trust has improved since 2015 although remains below the national average

If a respondent answered� Their response would

score�

Strongly disagree 1

Disagree 2

Neither agree or disagree 3

Agree 4

Strongly agree 5

Key Findings• While the Trust remains on or below average on many scores, there are significant

improvements in many areas. This is particular evident in the senior manager scores.

The Trust’s 2016 Overall Engagement score is just below average for the sector (Trust

3.76, sector 3.80).

Top ranking scoresThe table below highlights the five key findings for

which BCPFT compares most favourably with other

combined Mental Health/learning disability and

community trusts in England. The accompanying

graphs illustrate how the Divisions compare across

the Trust.

Area Score Action in 2017

KF 11 Percentage of staff

appraised in last 12 months

96% compared to 92%

in other Trusts

Trust has commissioned the

internal auditors to audit the

quality of appraisals

Trusts KF29 Percentage of

staff reporting errors, near

misses or incidents

witnessed in the last month

95% compared to 93%

in other Trusts

Ensure that staff receive

feedback and continue with

systems that are in place and

the work carried out to

improve on reporting via the

Trust incident management

system Datix

KF2 Staff Satisfaction with

the quality of work and care

they are able to deliver

3.95 compared to 3.89

in other Trusts

Continue the work to

support staff to be able to

carry out their roles to a

satisfactory standard


KF16 Percentage of staff

working extra hours

69% compared to 71% in

other Trusts

Will be supporting staff

to understand the

rationale for long hours

and ensuring support is

in place to take back

hours and to have a fair

process for flexible

working arrangements

KF27 Percentage of

staff/colleagues reporting

most recent experience of

harassment, bullying or

abuse is at

59% compared to 58% in

other trusts

This is another area the

Trust will be tackling

this year in terms of

managing the number

of areas being reported.

Bottom ranking scores• The table below highlights the five key findings

for which BCPFT compares least favourably with

other combined Mental Health/learning disability

and community trusts in England. The

accompanying graphs illustrate how the

Divisions compare across the Trust.

• These areas are recommended as a starting

point for local action to improve as an

employer.


KF 15 Percentage of staff

satisfied with the

opportunities for flexible

working patterns

52% compared to 58%

in other Trusts

Consider how to support fair

and flexible opportunities

KF22 Percentage of staff

experiencing physical

violence from patients,

relatives or public in last 12

months

22% compared to 15%

in other Trusts

MH Division to continue with

actions such as

implementing alternative

approaches in dealing with

violence and aggression in

keeping with Cambridge

Model. And to support

interventions early warning

systems (Level 1 debriefing)

KF30 Fairness and

effectiveness of procedures

for reporting errors, near

misses and incidents

3.60 compared with

3.77 in other Trusts

Ensure review systems and

procedures are monitored


KF19 Organisation and

management interest in and

action on health and

wellbeing

3.61 compared to 3.74 in

other Trusts

Continue to promote

the health and

wellbeing steering

group and the work

that is being carried out

to help support

improvements in staff’s

health and wellbeing

KF8 Staff satisfaction with

level of responsibility and

involvement

3.84 compared to 3.90 in

other Trusts

Continue with the

actions as outlined in

MH Enhancing staff

Experience around

improve overall staff

engagement and

involvement levels

2015 2016

o Able to do job to a standard they are pleased with 75% 76%óóóó

o Satisfied with extent org values their work 34% 42%ıııı

o Manager gives clear feedback on their work 61% 68%ıııı

o Communication between senior management and staff

effective

31% 37%ıııı

o Senior managers act on staff feedback 21% 27%ıııı

o Staff unwell because of work related stress 42% 40%óóóó

o They or colleague reported error 96% 98%óóóó

o They or colleague reported violence 87% 92%ıııı

o They or colleague reported HBA 58% 57%óóóó

o Staff experienced discrimination in last 12 months from public 10% 8%óóóó

o Staff experienced discrimination in last 12 months from

colleagues

7% 6%óóóó

o Had appraisal and/or review in last 12 months 96% 96%óóóó

o Care of patients is the organisation's top priority 62% 70%ıııı

Key Comparisons with 2015

Communication

As part of the Staff Engagement and Development Plan, the results have now been

communicated to staff via the range of methods below:

Action Date

Presentation from Quality Health to Management Board February

Information shared with Staffside colleagues February

Information included in Team Brief which follows a cascade system

for communicating within teams.

February

Update of information results, reports onto the Staff

Survey/Engagement section of the Trust Intranet page

February/ongoing

development

Report to the Board of Directors March

Inclusion of information in the Trust Annual Report April

Information included in the weekly E-bulletin February

Report to Commissioners via CQRM (Clinical Quality Review

Meetings)

April

Presentations to the Divisional Management Board April

• Next steps

• For more information please contact Gail Parry, Staff Engagement and Development Manager:

landline 0121 612 8160 mobile 07812 388825 email [email protected]

Action When

• The staff engagement Manager is working closely with leads from each of the divisions and the

communication team to ensure that planned interventions are communicated to staff and reported

accordingly via the appropriate governance and assurance process/ and appropriate

communication channels.

Ongoing

• Involvement and engagement of staff via the Transforming Care Together (TCT) Organisational

Development Workstream action plan will be key as this is responsible to lead on culture and

leadership programme and there are planned focus groups, workshops and a number of large scale

events being planned.

May onwards

• Organise an Annual Awards event in September to celebrate Staff achievements and to combine

this with having a membership and Annual General meeting

September

• Meet with the internal auditors who undertook a review of the current appraisal system to get

feedback and take on any recommendations

May

• Have an overview of flexible working opportunities to ensure they continue to be accessible and as

equitable to all as reasonably possible within service capability

• To have an overview of interventions to reduce the number of reported incidents of violence and

aggression, through appropriate policies and procedures, and to cross reference any

information/data that we are able to share from Freedom to Speak up (FTSU) Guardian and FTSU

Champion roles.

Ongoing

• The Equality and Inclusion Board to continue to manage and monitor the Workforce Race Equality

Standard (WRES) action plan.

Ongoing

And finally1. some comments left by responders

• Things have been very difficult and very little support but this is slowly changing now.

• Can do better

• The support for service advancement and transformation has been excellent

• The leadership team is responsive, open and honest and has a really good presence amongst the

workforce

• I feel more and more is expected and people are near breaking point

• The NHS runs on good will and I see this disappearing every day

• This organisation does not appear to value or harness the experience of its ground level staff

• Negative feedback from senior management and positive feedback mostly from colleagues and line

managers

• Funding is always an issue regarding professional development

• I am watching colleagues burn out in front of me

• The organisation is struggling due to cuts across public funding

• Too many meetings discussing same issues

• Our team is very fortunate to have a fantastic line manager

Public Document Pack - bcpft.nhs.uk

Documents

Transcript of Public Document Pack - bcpft.nhs.uk